REPORT TO THE EMCDDA by the Reitox national focal point of Greece, University of Mental Health Research Institute (UMHRI)
GREECE DRUG SITUATION 2000
REITOX REF/ 2000 University Mental Health Research Institute Director: Professor C.N. Stefanis
GREEK REITOX FOCAL POINT
ANNUAL REPORT on the DRUG SITUATION Submitted to the E.M.C.D.D.A. 2000
Plagianakou, S., M.Sc. – Terzidou, M., M.Phil – Yotsidi, V., M.A.
Compilation of data: Maka, Z., M.Sc. Plagianakou, S., M.Sc. Siamou, I., B.A. Terzidou, M., M.Phil. Yotsidi, V., M.A.
Statistical analysis: Grimani, I., M.Sc. Spyropoulou, M., M.Sc. Contact: Greek REITOX Focal Point University Mental Health Research Institute P.O. Box 66 517 15 601 Athens Greece
tel: 0030 1 65 36 902 fax: 0030 1 65 37 273 e-mail: [email protected]
Cover Design: Kokkevi, A. DeskTop Publishing: Angelopoulou, K. Graphs: Foundoukas, M. We heartily want to thank our colleague Chryssi Lyraki for her overall contribution and support in the preparation of this report
Manina, Stavroula, Vicky TABLE OF CONTENTS
INDEX/LIST OF ABBREVIATIONS
SUMMARY: MAIN TRENDS AND DEVELOPMENTS
PART I. NATIONAL STRATEGIES: INSTITUTIONAL AND LEGAL FRAMEWORKS………………………………………...... …...... ………. 2
1. Developments in Drug Policy and Responses ………………………………. 2 1.1 Political framework in the drug field……………………………………………… 3 1.2 Policy implementation, legal framework and prosecution …………………….. 5 1.2.1 Drug laws …………………………………………………………………… 5 1.2.2 Prosecution policy: priorities and objectives …………………………….. 8 1.3 Developments in public attitudes and debates…………………………………. 10 1.3.1 Public debates ……………………………………………………………… 10 1.3.2 Public attitudes……………………………………………………………… 11 1.3.3 Media presentation and image of drug use……………………………… 13 1.4 Budgets and funding arrangements …………………………………………….. 14 1.4.1 Funding at national level…………………………………………………... 14 1.4.2 Geographical differences………………………………………………….. 17
PART II. EPIDEMIOLOGY……………………………………………………...... … 19
2. Prevalence, Patterns and Developments in Drug Use …………………….. 20 2.1 Main developments and emerging trends ……………………………………. 20 2.1.1 Drug use in a changing society ………………………………………… 20 2.1.2 Social attitudes ………………………………………………………….. 20 2.1.3 Youth culture …………………………………………………………….. 21 2.1.4 Availability of drugs ……………………………………………………… 22 2.2 Drug use in the population …………………………………………………….. 23 2.2.1 General population surveys …………………………………………….. 23 2.2.2 School population surveys ……………………………………………… 25 2.2.3 Geographical distribution of drug use …………………………………. 28 2.2.4 Discussion ………………………………………………………………... 32 2.3 Problem drug use ……………………………………………………………….. 32 2.3.1 Adolescents and young adults drug users ……………………………. 33 2.3.2 Risk behaviours ………………………………………………………….. 34 2.3.3 Dropping-out of treatment ……………………………………………… 38
3. Health consequences ……………………………………………………………... 38 3.1 Drug treatment demand ……………………………………………………….. 38 3.1.1 Summary of the characteristics of all clients who requested treatment in 1999 ………………………………………………………... 39 3.1.2 Characteristics of new clients in 1999 ………………………………… 40 3.1.3 Different client profiles in different types of treatment ………………. 42 3.1.4 Treatment demand for cannabis ………………………………………. 47 3.1.5 Comparisons of all client characteristics between 1996-1999 …….. 49 3.2 Drug related mortality ………………………………………………………….. 52 3.2 Drug related infectious diseases ………………………………………………. 55 3.3.1 HIV/AIDS …………………………………………………………………. 55 3.3.2 Hepatitis B and C ……………………………………………………….. 55 3.3.3 Tuberculosis ……………………………………………………………... 56 3.4 Other drug related morbidity …………………………………………………...... 56 3.4.1 Psychiatric co-morbidity ………………………………………………… 56
4. Social and legal correlates and consequences ……………………………... 59 4.1 Social problems ………………………………………………………………… 59 4.4.1 Social exclusion …………………………………………………………. 59 4.4.2 Minorities …………………………………………………………………. 60 4.4.3 Community problems …………………………………………………… 60 4.2 Drug offences and drug related crime ……………………………………….. 60 4.2.1 Arrests and charges …………………………………………………….. 60 4.2.2 Convictions and imprisonments ……………………………………….. 61 4.2.3 Drug related crime ………………………………………………………. 63 4.3 Social and economic costs of drug consumption …………………………… 64
5. Drug markets ………………………………………………………………………... 64 5.1 Availability and supply …………………………………………………………. 64 5.2 Drug seizures ……………………………………………………………………. 65 5.2.1 New trends in drug trafficking ………………………………………….. 67 5.3 Price and purity …………………………………………………………………. 67
6. Trends per drug ……………………………………………………………………. 68 6.1 Cannabis ………………………………………………………………………… 68 6.2 Synthetic drugs ………………………………………………………………….. 69 6.3 Heroin/opiates …………………………………………………………………... 70 6.4 Cocaine ………………………………………………………………………….. 70 6.5 Multiple use ……………………………………………………………………… 70
7. Conclusions …………………………………………………………………………. 72 7.1 Consistency between indicators ………………………………………………. 72 7.2 Implications for policy and interventions ……………………………………… 73 7.3 Methodological limitations and data quality ………………………………….. 73
PART III. DEMAND REDUCTION INTERVENTIONS………………………… 75
8. Strategies in Demand Reduction at National Level ………………………… 76 8.1 Major strategies and activities ………………………………………………… 76 8.2 Approaches and new developments ………………………………………….. 77
9. Intervention Areas …………………………………………………………………. 82 9.1 Primary Prevention ……………………………………………………………… 82 9.1.1 Infancy and family ………………………………………………………. 82 9.1.2 School Programmes ……………………………………………………. 83 9.1.3 Youth programmes outside schools …………………………………… 86 9.1.4 Community programmes ……………………………………………….. 87 9.1.5 Telephone help lines …………………………………………………. 89 9.1.6 Mass media campaigns ………………………………………………… 90 9.1.7 Internet …………………………………………………………………… 91 9.2 Reduction of drug related harm ……………………………………………….. 92 9.2.1 Outreach work …………………………………………………………. 92 9.2.2 Low threshold services …………………………………………………. 93 9.2.3 Prevention of infectious diseases ……………………………………… 95 9.3 Treatment ………………………………………………………………………….. 95 9.3.1 Treatments and health care at National level ………………………… 95 9.3.2 Substitution and maintenance programmes ……………………….. 101 9.4 After-care and re-integration ……………………………………………….. 103 9.5 Interventions in the Criminal Justice System ……………………………… 105 9.6 Specific targets and settings ………………………………………………… 107 9.6.1 Gender specific issues ……………………………………………….. 107 9.6.2 Children of drug users ………………………………………………… 108 9.6.3 Parents of drug users ………………………………………………… 109 9.6.4 Drug use at the workplace …………………………………………… 109 9.6.5 Ethnic minorities ………………………………………………………. 110 9.6.6 Self-help groups ………………………………………………………. 112 9.6.7 Alternatives to prison and prosecution …………………………….. 112
10. Quality Assurance …………………………………………………………………. 113 10.1 Quality assurance procedures ……………………………………………… 113 10.2 Treatment and prevention evaluation ……………………………………… 118 10.3 Research ………………………………………………………………………. 121 10.4 Training for professionals ……………………………………………………. 126
11. Conclusions: Future Trends ……………………………………………………. 130
PART IV. KEY ISSUES …………………………………………………………. 131
12. Drug Strategies in European union member states ………………………… 132 12.1 National policies and strategies ………………………………………………….. 132 12.2 Application of national strategies ………………………………………………… 134 12.3 Evaluation of national strategies…………………………………………………. 137
13. Cocaine and base/crack cocaine ……………………………………………… 138 13.1 Different patterns and users groups……………………………………………… 138 13.1.1 Epidemiological data …………………………………………………….. 138 13.1.2 Data from dependent individuals ……………………………………….. 138 13.2 Problems and needs for services………………………………………………… 139 13.3 Market ………………………………………………………………………………. 139 13.3.1 Purity and price …………………………………………………………… 139 13.3.2 Trafficking, dealing and distribution patterns ………………………….. 140 13.4 Intervention projects ………………………………………………………………. 140
14. Infectious diseases ………………………………………………………………….. 140 14.1 Prevalence of HCV, HBV and HIV among drug users………………………… 140 14.1.1 Hepatitis …………………………………………………………………… 140 14.1.2 HIV/AIDS ………………………………………………………………….. 143 14.1.3 Data on infectious diseases from special studies …………………….. 144 14.2 Determinants and consequences………………………………………………… 146 14.3 New developments and uptake of prevention, harm reduction and care …………………………………………………………………….……… 145
REFERENCES……………………………………………………………………149
References and sources of information ……………………………………………. 150 ANNEX ……………………………………………………………………………………….. 155
Table I. Prevention Centres established by OKANA (1997-2000) ……………………. 156 Table II. Treatment units, geographical location & coverage …………………………… 158 CONTENTS OF TABLES
PART I. NATIONAL STRATEGIES: INSTITUTIONAL AND LEGAL FRAMEWORKS
Table 1. Public expenditure on drugs ……………………………………………………. 15
PART II. EPIDEMIOLOGY
Table 2. Use of psychotropic substances by high-school students: data from the University of Ioannina survey………………………………………… 27
Table 3. Demographic characteristics of drug users among prison inmates in 1995 ………………………………………………………………….. 31
Table 4. Needle sharing among Greek IVDUs as reported in different studies in 1991-1993 ……………………………………………………………. 35
Table 5. Changes in the risk behaviours of Greek intravenous drug users between 1993 and 1998 …………………………………………………. 36
Table 6. Characteristics of users starting treatment …………………………………… 41
Table 7. Number of individuals seeking treatment in different types of treatment during 1999…………………………………………………………… 42
Table 8. Number of individuals demanding treatment in 1996 and 1999 ……………. 50
Table 9. Characteristics of drug related death cases in 1995-1999 ………………….. 54
Table 10. Sources and nature of information on Hepatitis B and C and status of collaboration with the Greek GP in 2000 …………………………… 55
Table 11. Drug seizures in 1999 made by each of the law enforcement authorities ………………………………………………………………………… 66
Table 12. Retail and trafficking drug prices in 1999 (in EURO)………………………… 68
PART III. DEMAND REDUCTION INTERVENTIONS
Table 13. Evaluation results of the “Parents’ School” programme of the Prevention Centre “PYXIDA” …………………………………………………… 83
Table 14. Objectives of the school prevention programmes according to their target-groups ………………………………………………………………. 84
Table 15. Students’ replies regarding changes in attitudes and knowledge following the programme “Prevention of drugs, promotion of interpersonal relations and combating academic stress”……………………. 86 Table 16. Staffing of the therapeutic programmes in 1999……………………………… 96
Table 17. Funding sources of the therapeutic programmes ……………………………. 97
Table 18. Specific criteria in the prevention field according to the formal requirements for quality assurance……………………………………………. 115
Table 19. Structures and types of training in the prevention field ……………………... 127
PART IV. KEY ISSUES
Table 20. Prevalence of HIV and hepatitis in Greek prisoners ………………………… 144
Table 21. Programmes and interventions for combating infectious diseases………… 146 CONTENTS OF FIGURES
PART II. EPIDEMIOLOGY
Figure 1. Drug use by young club/party goers and the general population ………..… 21
Figure 2. Drug use in the general population by gender …………………………..…… 24
Figure 3. Lifetime drug use in high-school students from the ESPAD study ……..….. 26
Figure 4. Geographical distribution of illicit drug use among high-school students ……………………………………………………………………..…… 28
Figure 5. Use of psychotropic substances by high-school students in three major Greek cities…………………………………………………………. 29
Figure 6. Geographical distribution of illicit drug use among the general population ………………………………………………………………..……….. 29
Figure 7. Characteristics of adolescents and young adults drug users requesting treatment at “STROFI” in 1998-1999 …………………..………… 34
Figure 8. Risk behaviours among adolescent and young adults drug users ……..….. 37
Figure 9. Sociodemographic characteristics of new clients ……………………….…… 40
Figure 10. Age distribution of clients in drug-free and substitution programmes ………………………………………………………………………. 43
Figure 11. Labour status of clients in drug-free and substitution programmes ………………………………………………………………………. 43
Figure 12. Age distribution of clients in out-patient and in-patient programmes ………………………………………………………………………. 45
Figure 13. Labour status of clients in out-patient and in-patient programmes ………………………………………………………………..……. 45
Figure 14. Primary substance used by clients in out-patient and in-patient programmes …………………………………………………………………..…. 46
Figure 15. Number of substances used by clients in out-patient and in-patient programmes ……………………………………………………..…… 47
Figure 16. Sociodemographic characteristics of cannabis use……………………..…... 48
Figure 17. Number of substances used by cannabis and opiate users …………..……. 49
Figure 18. Labour status of clients demanding treatment in 1996 and 1999 ………..… 51
Figure 19. Living status of clients demanding treatment in 1996 and 1999 …………….. 52
Figure 20. Drug related deaths (1985-1999) ………………………………………….….. 53 Figure 21. Arrests and charges by the Hellenic Police and charges by the law enforcement authorities (1994-1999) ……………………………..…. 61
Figure 22. Individuals imprisoned for drug law offences (1995-1999) ……………..…... 62
Figure 23. Imprisoned individuals for drug law offences according to type of offence (1996-1997) ……………………………………………………….… 62
Figure 24. Burglaries in pharmacies in Greece (1991-1999) ……………………..…….. 64
Figure 25. Seizures of heroin, cocaine and herbal cannabis (1991-1999) ……………... 65
Figure 26. Simultaneous use of ecstacy and other substances by 69 high-school students and club/party goers ………………………………..….. 69
Figure 27. Number of substances used by clients requesting treatment in 1996 and 1999 ………………………………………………………..………. 71
Figure 28. Very frequent alcohol consumption among drug users and non-users between 1984 and 1998 ………………………………………..…. 71
PART II. EPIDEMIOLOGY
Figure 29. Prevention centres established by the OKANA per year of inauguration ………………………………………………………………..…. 78
Figure 30. Types of therapeutic programmes in 2000 ………………………………….... 95
PART IV. KEY ISSUES
Figure 31. Test results for Hepatitis C as reported by the various relevant sources in 1999 ……………………………………………………….. 141
Figure 32. Self-reports for Hepatitis C in 1999 ……………………………………………. 142
Figure 33. AIDS cases among drug users (1985-1999) ………………………………… 143 L II S T O F A B B R E V II A T II O N S
Term Definition
ESPAD European School Survey Project on Alcohol and Other Drugs
FESAT European Foundation of Drug Help-Line
KEEL Centre for the Control of AIDS & STD’s
KETHEA Centre of Therapy for Dependent Individuals
NA Narcotic Anonymous
NSPH National School of Public Health
OKANA Organization Against Drugs
UMHRI University Mental Health Research Institute SUMMARY
MAIN TRENDS AND DEVELOPMENTS
A. Epidemiology
Most indicators point at an aggravation of the drug problem in Greece.
Increased number of young people experiment with drugs, mainly for recreational purposes. The representation of women among drug users increases.
Drug use is spreading to all geographical strata and it is quite prevalent to special social groups, such as prison inmates.
Dependent users requesting treatment have also increased in both substitution and drug free programmes. New clients, i.e. those requesting treatment in 1999 for the first time seem to share similar characteristics with old clients: they are mostly young males, unemployed, opiate users. Clients in methadone substitution programmes differ from clients in drug-free or in-patients programmes, as they are selected following strict criteria.
Cannabis users who demand treatment have a different profile from heroin users: they are younger, and they use multiple drugs or inject to a lesser extent than heroin users.
Risk behaviours continue to be exhibited by high percentages of dependent users. Although AIDS infection is much lower than in other European countries, hepatitis, especially C, is spread to the majority of injecting drug users.
The rate of drug related deaths, which appeared stabilising in the previous years, increased sharply in 1999.
Due to its geographic position, Greece had always had to deal with drug trafficking across borders, especially trafficking from Asia and Africa to Europe. The main trafficking route is the sea, although new trends emerge, such as the “mailing” of drugs.
Drug production is a totally new trend for Greece, which was revealed with the seizure of large amounts of precursor substances and amphetamines in a production “industry”.
B. Policy
Having adopted since 1987 a more lenient approach towards drug use and drug users compared to the previous status, Greek legislation on drugs seems nowadays as being more attuned to the European one by trying to achieve a balance between repressive and preventive initiatives. The emphasis put on either level of confrontation of the problem seems to follow overall changes of social life. Having taken into account the increase observed in drug use prevalence Greek prevention policy is orientated towards the reinforcement of primary prevention activities either by supporting and further expanding Primary Prevention Centers or by promoting their inter-communication and cooperation. Related are also future plans for putting more emphasis on research and evaluation as well as on professional and educational training on primary prevention. Data regarding problematic drug use indicate, moreover, a need for an increase in availability of treatment programmes, a need that has already been set as a priority by OKANA as has also been the expansion of treatment units for adolescents in many Greek cities.
Initiatives and plans have also been organized at the level of law enforcement. Repressive measures have been undertaken or formed under two major scopes: frontier drug trafficking and increased criminality observed in particular inland municipalities, whereas plans to facilitate the judicial procedure in general include also re-examination of the drug laws or changes in the sentences’ imposition.
The public bodies that are actively involved in policy making and application at all levels of confrontation, i.e. Ministries, local authorities, treatment and prevention services, are represented in the steering committee of OKANA, who constitutes the central coordinating body responsible for policy making at all levels of prevention. The Central Anti-drug Coordinating Unit, on the other hand, has assumed coordinating and administrative responsibilities at the level of repression. However, the combination of the different philosophies of the authorities involved at all the levels of confrontation should facilitate furthermore a holistic approach to the phenomenon of drugs. Moreover, under the scope that OKANA has been entrusted with the inter-ministerial coordination, its legal basis, as has also been argued by the previous All-Party Parliamentary Committee, should come under re-examination, so that it would lend it prestige, flexibility and autonomy to act as an intermediary agent more effectively.
Public and political debates have often been raised during the reporting year, mainly due to two major facts: the oncoming parliamentary elections in April 2000 and the issue of the administration of drugs besides methadone, that was set by two governmental members. The political debates were widely hosted in the press. The latter contributed also to the general formation of the drug use image. The core of the press argumentation was young generations and drug use as well as the “visualization” of drug addicts as “victims” and of drug dealers as “victimizers”.
C. Demand Reduction
Following the proliferation of the prevention and the therapeutic programmes during the last three years, emphasis was given in 2000 on the development of new services and on the promotion of quality assurance in the demand reduction field. Within this framework, combined efforts from policy makers and professionals working in the drugs field focused on acknowledging the gaps at the provision of services in terms of both quantity and quality as well as on taking action to respond to the drug users’ needs more effectively.
On these grounds, nine new prevention centres were inaugurated, while health promotion programmes that take place under the initiative of the Ministry of Education were increased. The main focus of policy regarding primary prevention was on the improvement of prevention interventions, through the establishment of systematic training in evaluation issues as well as through the reinforcement of co-operation among all the responsible agencies.
Based on research data and clinical experience, new therapeutic and harm reduction programmes were created in order to cover the demand for treatment agencies at local and regional level as well as to respond to the needs of specific groups of drug users. Within this framework, the first methadone maintenance unit was inaugurated in Athens, many of the existing regional therapeutic programmes have expanded their services to adolescents drug users, and street-work programmes were increased at the local communities. Moreover, an innovative initiative in 2000 was the development of the Support Centre for Prisoners and Discharged Prisoners in Thessaloniki, which aims at harm reduction, enhancing motivation to treatment, rehabilitation and social reintegration.
The vocational and social rehabilitation of former drug users was another area of intervention on which emphasis was laid. Having being initiated in 1998- 1999, the development and implementation of vocational training programmes were systematized in 2000. Moreover, new rehabilitation programmes were developed for former drug users as well as for long-term substitution clients. The Ministry of Labour and Social Welfare continued in 2000 to provide subsidies to ex-addicts and to discharged prisoners who start working at the private sector or want to run their own business.
Training of professionals was also reinforced through the publication of new educational materials, the organization of seminars and conferences on a more systematic basis and the co-ordination of meetings to exchange experience and opinions. The main themes of these training programmes concerned effective methods of intervention in different scopes of work (i.e. prevention at the primary education, drug counselling, street-work programmes) as well as the promotion of an evaluation culture in the demand reduction field.
Several interventions ranging from education on safe drug use and safe sex to syringe exchange, testing and treatment are currently provided by most demand reduction agencies in order to prevent infectious diseases and to promote harm reduction from drugs. However, it appears to be necessary for the respective programmes to be further expanded, especially at the local and the regional level. PART I
NATIONAL STRATEGIES: INSTITUTIONAL AND LEGAL FRAMEWORKS
1 1. DEVELOPMENTS IN DRUG POLICY AND RESPONSES
1.1 Political framework in the drug field
Since the enactment of Law 1729/1987 Greek legislation on drugs adopted a more lenient approach towards drug use and drug users by departing from being a clearly corrective policy alone and becoming at the same time a preventive one as well. Differences from the previous legislative status focused mainly on the establishment of dissimilar confrontation of addicted drug users and of drug dealers, on regarding the former as “patients” needing medical attention and on the emphasis put on prevention. Amendments of the 1987 Law ever since as well as enactment of new laws reinforced this more humanistic model enabling the implementation of harm reduction initiatives and the protection of drug related offenders by acknowledging extenuating circumstances for them.
The state’s intention to confront the drug problem in a more comprehensive way is indicated by initiatives that have been undertaken in regard to several dimensions of the phenomenon. Repression and prevention policies appear more balanced and emphasis on either level of confrontation is put following social changes. The acknowledgement and the acceptance on the side of the state of the existed drug use prevalence, that seemed to be on the rise, as well as of the existed demand for therapy led to the inauguration of both demand and harm reduction activities. On the other hand, drug trafficking through and within Greece that is nowadays viewed as part of the international organized crime is considered to be facilitated by changes in the near Balkan countries during the last decade and mainly by the opening of their boundaries. Foreigners entering Greece in illegal ways constitute, according to the police, a major problem, since many of them are involved in drug trafficking and assume an important role in the visualization of Greece as a “cross-road for drugs”. The above estimation has led prosecution authorities to reinforce the frontier guard without weakening at the same time inland manpower.
New developments for the reporting year and plans for the near future are presented below in regard to three different domains: prevention, repression and justice
Prevention
The Organisation Against Drugs (OKANA) under the umbrella of the Ministry of Health is the central coordinating body, responsible in policy making in the domain prevention. OKANA (2000) has published a three year action plan covering all levels of prevention.
Primary prevention
2 Priorities that have been set by OKANA in regard to primary prevention refer mainly to the expansion of Prevention Centers so as to cover every Greek prefecture by the end of 2001 as well as to the increase of OKANA’s Prevention Department manpower both under the scope of protecting and promoting the prevention centers’ institution. Moreover, to improve electronic communication among the centers as well as between the centers and OKANA or their supporter agencies, OKANA plans for the supplying of a unified electronic information system. As regards professionals’ training in prevention, OKANA plans to systematize the training activities’ supervision, to publish respective reference books, to establish libraries in all prevention centers as well as to cooperate with the Ministry of Education and the country’s universities so that prevention training will be included in the basic university education.
Secondary prevention
Data regarding the needs for therapy indicate that the respective planning should aim at the increase of treatment programmes’ availability. OKANA’s priority is to see to the establishment of new treatment units in cooperation with the local and scientific authorities. The new units should include drug-free programmes, substitution detoxification and substitution maintenance programmes. Some of them have already been inaugurated. Moreover, a Help-center and a Mobile Unit are foreseen for North Greece.
The establishment of treatment units for adolescents in many cities is another major priority set by OKANA, who examines the possibility to cooperate with local agencies in the respective areas in order to achieve his goal. Educational training for treatment professionals is also among OKANA’s plans as well as cooperation with the Ministry of Education under the scope of including in the university syllabus a special subject about drug addiction.
Tertiary prevention
In April 2000, a Centre of Vocational Training has been inaugurated by OKANA, subsidized by European Community Pay Office as well as by the Ministry of Labour. The Centre aims at the professional and social rehabilitation of 90 ex drug-addicts.
Research and evaluation
The promotion of research and evaluation is among OKANA’s three-year action plan. To achieve an improved organization and coordination of research and evaluation programmes, OKANA sees to enact a Research and Evaluation Department.
3 Broadening of OKANA’s subject
The observed correlation of use between legal and illegal substances establishes, according to OKANA, the need for an overall confrontation of licit and illicit substances’ use. This realization on the side of both the state and the public constitutes a prerequisite towards the direction of treating problematic alcohol-users and users of other licit substances as well.
Repression
The Central Anti-Drug Coordinating Unit coordinates repression policy against drugs that is applied by four public bodies: the Police (Ministry of Public Order), the Customs (Ministry of Finance), the Financial and Economic Crimes Office (Ministry of Finance) and the Coast Guard (Ministry of Merchant Marine). During the reporting year repressive measures have been intensified and new plans have been formed under two major scopes: frontier drug trafficking and increased criminality observed in particular inland municipalities.
The geographical position of Greece constitutes an aggravating factor for frontier drug trafficking, because of which Greece has been often characterized as a “gateway for narcotics”. To reinforce the frontier guard the police have established a frontier-police unit consisting of 2200 men, whereas the Ministry of Public Order has already started to provide the frontier posts with highly developed electronic equipment. Both initiatives appeared as imperative all the more so since the official enactment of the Schengen agreement in Greece on the 1st January of 2000. Moreover, the Ministry examines the possible ways for the upgrading and expansion of the Police Drug Prosecuting Units and the establishment of respective units in risky frontier and urban areas. Frontier policy against drugs has been moreover reinforced by the bilateral agreement signed between Greece and Turkey regarding among others the combat against illegal drug trafficking as well as by the agreement memorandum for cooperation signed between the General Customs Directorate and a private express mail transport company.
To confront inland drug problem the police implemented or is up to implement measures, that although they are mainly repressive they touch upon prevention as well. In particular, pedestrian police patrols that have been established by the Ministry of Public Order are considered to contribute to the confrontation of the urban criminality, whereas among the repressive policy plans is also the establishment of armed city-police units that will be competent to make assaults in night clubs after accusations for drug dealing. Similarly, the reinforcement of police forces in tourist areas, especially during the summer season, in order to combat imported drugs is also under consideration, as is also testing car-drivers for drug consumption. Besides repressive measures, however, the Minister of Public Order plans also the involvement of police in the domain of prevention in cooperation with the other competent authorities. Police preventive measures will take the form of information campaigns launched by specialized policemen, police presence
4 outside schools as well as cooperation with the local communities for the detection of causes that lead to drug-related problems.
Justice
In order to overcome overpopulation problems in custodial institutions as well as to accelerate case hearing process the Minister of Justice is promoting a pilot programme that includes a variety of measures. The proposed measures aim at changes in the legislative status, on the one hand, and in the judicial process, on the other. In particular, the entering into force of inactive legal provisions such as alternative measures to imprisonment is under consideration as is also the imposition of administrative measures instead of criminal penalties for actions of no serious social demerit. Under examination are also offences included in the Law against drugs, although the direction of the in question reform is not known yet.
Moreover, the imposition of strict measures for inexcusable delay in passing judgements, the reduction in number of trial postponements as well as the establishment of new courts are planned in order to facilitate and to accelerate the case hearing process.
1.2 Policy implementation, legal framework and prosecution
1.2.1 Drug laws
· 1987
The 1987 Law ( 1729/87) provided for the legal aspects concerning drugs as well as for the development of services in the domains of prevention, therapy and rehabilitation. More specifically, drug users were separated in dependent and non-dependent. The latter if arrested for personal use for the first time were obliged to follow a counseling program. Dependent users having committed any criminal offence were obliged to follow a detoxification program either in prison or in a public hospital. The time spent in treatment was equivalent to the time the offender would spend in prison.
· 1993
According to Law 2161/93 OKANA (The Greek Organisation Against Drugs) was established as a self-regulating legal entity under the Ministry of Health. The above law introduced also several provisions such as the criminalisation of precursor substances, the possibility of substitution treatment in special public units, the controlled transportation concept as described in the 1988 U.N. Convention and the severe penalties for doctors and pharmacists who did not follow the rules for drug prescription.
5 · 1995
Law 2331/95 clarified that the postponement of the penal prosecution against dependent drug-law offenders would be possible, if the director of a licensed Drug Treatment Service submitted an official report to the District Attorney declaring that the offender had voluntarily begun and was systematically attending the treatment provided by the Service. If the offender completed treatment successfully, prosecution could be permanently suspended.
The above law criminalised also the laundering of all criminal proceeds, including drug trafficking.
· 1996
Law 2408/96 introduced a more lenient treatment of dependent users violating drug laws, since offences of dependent users were to be treated as misdemeanors and not as felonies. In 1997, two amendments of the 1996 Law reintroduced the characterisation of drug dealers as “especially dangerous” and laid down special penalties for dealers selling drugs to children.
· 1997
Ministerial Decree 33682/27-6-1997
This decree issued by the Ministry of Labour and Social Welfare provides for the three-years subsidize of employers to employ 290 ex-drug addicts, ex- prisoners and young delinquents. In particular, three out of the five programmes that have been organized by the Ministry of Labour, refer to the creation of job opportunities for former drug addicts. Age-range for former drug addicts is from 16 to 65 years old and the daily amount of subsidize ranges from 11.7 EUROs (for part-time occupation) to 22 Euros for full-time occupation during the third year.
Ministerial Decree 33779/15-7-1997
Issued by the Ministry of Labour and Social Welfare, this decree provides for the subsidize of new free-lancers aged from 18-60 years old. This subsidize is addressed to former drug-addicts and discharged prisoners. Subsidize duration is for 24 months whereas the amount of subsidize is 3521.6 Euros per year. Annual increments are provided for new free-lancers if their enterprise is created in border, island or downgraded areas.
6 · 1999
Law 2721/99
Law 2721/99 provided for the more lenient treatment of drug users in case of trafficking of small drug amounts. More specifically, trafficking of small amounts of drugs between users proven to be exclusively for personal use is since June 1999 considered as misdemeanor and not as felony, since it can lead to 6 months imprisonment that could be either exchanged with a fine or suspended.
Moreover the above law provided also for drug-dependent offenders who committed some criminal act in order to facilitate drug use. In case this act is not against human life, personal freedom and physical integrity the offender can have his penal prosecution postponed or even permanently suspended if he achieves detoxification on his own providing that a public hospital or licensed drug treatment service in Greece or in the European Union verifies that his addiction started before the commission of the criminal act. Moreover, his detoxification should be also verified by a licensed drug treatment service after the offender had attended a treatment program for at least six months.
Law 2721/99 included also the establishment of two detoxification units for drug-dependent prisoners one in Thiva (Central Greece) and one in Chalkidiki (North Greece) aiming at the physical as well as psychological detoxification of drug-dependent prisoners.
Law 2716/99
The 2716 Law of 1999 officially provided for the administration of substitutes of drugs in licensed public units and in units of OKANA. Pilot substitution treatment programs had been inaugurated in Greece since 1996 by OKANA, with the administration of methadone. According to the above law the substitution substances and the conditions of administration will be decided by ministerial decrees.
Law 2776/1999 - Penitentiary Code
Law 2776/1999 provides for the establishment of the category specialized detoxification prison units among the various sorts of custodial institutions. The two established Detoxification Centers for Drug-depended Prisoners were placed under this category.
Ministerial Decree 149020/2-12-99
Signed by both the Minister of Health and the Minister of Justice, this decree provided for the formation of the therapeutic programme that will be
7 implemented in the Detoxification Centers for Drug-depended Prisoners. A specialized council will select drug dependent prisoners, who should be admitted in the centers. Three types of treatment programmes will be implemented within both Centers: a) a drug-free programme for individuals over 21 years of age, b) a drug-free programme for individuals up to 21 years old and c) a substitution programme with the administration of methadone.
· 2000
Ministerial Decree 3183/12-5-00
This decree refers to a specific proprietary medicine containing Buprenorphine. Although Buprenorphine is under Table D of the law against drugs since 1987, this ministerial decree provides for its administration in the form of the specific medicine exclusively within detoxification centers licensed to administrate substitution substances.
Ministerial Decree 3807/31-7-00
The decree refers to the classification of Norephedrine (Rhenylpropanolamine) as precursor substance under Table I of article 9 in Law 2161/1993.
Ministerial Decree 3225/2-10-00
Classification of the substances Medetomidine, Atipamezole and Romifidine under Table C of Law 1729/1987.
1.2.2 Prosecution Policy: priorities and objectives
If someone is arrested for cannabis, heroin or cocaine possession the police are obliged regardless of the type of substance and the amount seized to commit the offender to the district attorney, the only authority responsible to press charges against the offender.
Non addicted arrested users are brought to trial without being taken into temporary custody. Accidental users, who are arrested, are committed to the district attorney but it is possible that they will never be brought to trial. Addicted users, who are arrested, have the possibility to spend some hours or days at the hospital instead of jail or they are released after the charges have been brought against them.
The court decides upon the penalty that will be imposed. According to law 2161/93 for the determination of the sentence the court takes into consideration the amount of the seized substance, so that it can decide that it was exclusively for personal use. Moreover, the degree of harm induced by
8 the specific substance and the table into which the substance is classified according to law 1729/87 is also taken into account before the determination of the sentence. In practice, there have been cases observed where possession of a small amount of cannabis was more strictly punished than possession of a small amount of heroin on the grounds that heroin causes addiction and thus arrested users were in need, whereas cannabis does not. Addicted users go unpunished since detoxification units in prisons, that according to law 1729/87 the offender was obliged to attend, do not exist until now. Non-addicted users who are arrested for the first time are obliged to follow a counseling program.
Charges for trafficking of drugs are pressed against the offender accordingly to the amount of drugs seized or to the information that the police have on the offender. In case the police are informed that someone is trafficking drugs, they arrest users who obtain drugs from him in order to verify his identity as drug-dealer and after the positive verification charges against the offender are pressed for trafficking and not for use. In cases of drug trafficking the police investigate the offender’s residence as well, whereas in cases of plain drug use they do not.
The police have set priorities regarding the specific drugs whose trafficking should be firstly repressed. Heroin is considered as the “hardest” drug and thus it is the one that is prosecuted the most. Right after heroin ranks cocaine, then synthetic drugs and last ranks cannabis.
Users who are also involved in trafficking are committed to the examining judge who decides for their temporary detention in case there are reasons for it, e.g. if they are characterised as “especially dangerous”. However, they should be brought to trial no later than after 18 months. Addicted users involved in drug trafficking are facing up to 8 years imprisonment, whereas non-addicted offenders are facing life imprisonment.
Law 2721/99 provided beneficial provisions for drug users who exchange small amounts of drugs proven to be exclusively for personal use. Trafficking of small amounts of drugs between users is considered as misdemeanor that can lead to 6 months imprisonment that could be either exchanged with a fine or suspended.
Dependent offenders having committed some property crime in order to facilitate drug use could until June 1999 follow a licensed detoxification program according to law 2331/95 instead of being sentenced to prison under the condition that the treatment service would submit an official report to the District Attorney declaring that the offender had voluntarily begun and was systematically attending the treatment provided by the service. The time spent in treatment was equivalent to the time the offender would spend in prison. If the offender completed treatment successfully prosecution could be permanently suspended and if he was convicted for property offences that were committed before he begun to attend the treatment program, the imposition of the penalty was suspended for no less than 3 and no more than 6 years under the condition that the offender remained detoxified.
9 In June 1999, Law 2721 was passed that stipulates the above beneficial provisions also to those addicted offenders who have committed some property crime and who can achieve detoxification without attending a complete licensed treatment program. The necessary pre-conditions for the implementation of the above benefits are the following: 1) the verification of a public hospital or licensed treatment program that the addiction of the offender had started before the commission of the crime and 2) detoxification should be verified by a licensed drug treatment service after the offender had attended a treatment program for at least six months.
1.3 Developments in public attitudes and debates
1.3.1 Public debates
Drug issues become often a topic of public and political debates all the more so before parliamentary elections, which was the case in Greece for the reporting year. Platforms of the candidate parliamentary parties included issues referring to drugs either questioning the effectiveness of the existing governmental policy or forming specific proposals targeting on the confrontation of the problem.
The issue, however, that prevailed over the social, scientific and political debates was raised at the end of 1999 by two governmental members and referred to the expansion of substitution treatment. In particular, both members argued in favor of the controlled administration of other substances as well, besides methadone, to which drug addicts were addicted. Administration, as it was argued, should take place in public hospitals and medical centers to “drug addicts at a late stage”. Their proposal, they clarified, rested on the need of keeping drug addicts out of the drug markets as well as on the positive results that were observed in countries were such initiatives were implemented, especially as regards the decrease in the number of deaths and criminal offences. On the other side, reactions were raised referring to the vagueness of the term "drug addicts at a late stage" as well as to the “medicalization” of the problem. Solutions to the problem, as the opponents of that proposal argued, should not be based on maintenance programs but on the exploration of the causes of drug addiction. Moreover, they called upon morality issues as well as on practical difficulties in implementing such a proposal, due to the lack of the appropriate legal framework, whereas they objected that such initiatives, that had took place elsewhere were still under evaluation.
Another issue that raised a lot of political criticism was lack of definition of the term “small drug amounts” that determines if a quantity is possessed (Law 2161/1993) or disposed of (Law 2721/1999) for personal use. The Minister in charge argued that the definition of “small amount” for every addictive substance is not possible since new drugs in new form and package are every day on the “market”.
10 Finally, in the face of the Greek parliamentary elections in April 2000 political proposals outlined by the Youth Movements of several parties included among others decriminalization either of “soft” drug use or of all drug use. Thus, once again, the debate on the discrimination between “soft” and “hard” drugs and on the decriminalization of use that prevail over the general social dialogue during the last years was reflected in the political agenda.
1.3.2 Public attitudes
A view on the attitudes of the public towards drug issues is usually formed by the concentration of survey data carried out either by scientific or private organizations as well as by monitoring responses of certain professional, political or broader social groups towards matters of special public interest.
A nationwide drug survey on the drug prevalence carried out in 1998 by the University Mental Health Research Institute showed among others that the majority of the 12-64 year old population believed that as much use as distribution of cannabis and heroin should not be legalized1. However, great differences were observed between the attitudes of the public towards cannabis and heroin as well as in the changes of those attitudes towards each substance over the years. The legality of cannabis possession for personal use was supported by 22.4% of the population in 1998, whereas the respective percentage for heroin was 7.5%. In 1984 results from the previous original survey showed that attitudes in favor of possession for personal use were at 4.7% for cannabis and at 2.0% for heroin. Moreover, in 1998 22.7% believed that cannabis sale should be placed under governmental control (the respective rate in 1984 was 9.9%), whereas 10.8% believed the same for heroin (the respective rate in 1984 was 7.3%). It is, thus, strongly indicated that attitude changes over the years towards drug use refer mainly to cannabis, a substance for which 53% of the young adults believed that it was harmless or slightly harmful in 1998 ( Kokkevi et al. 2000).
Use and attitudes towards use seem to be strongly correlated, at least among high school students, as it is also argued in a doctoral dissertation thesis published in the current year (Dimitriou 2000 unpublished dissertation) . The survey carried out in 1997 in three large Greek cities (Athens, Patra and Ioannina) on 2123 students of the 12th grade showed that the use of psychotropic substances was significantly higher among students with a more permissive attitude. In another research, qualitative this time, drugs among teenagers were approached experimentally within the framework of the social representations theory (Katerelos in press). Considering illegality and addiction as the central elements in the social representation of narcotics it was found that addiction seems to have a larger impact than illegality among high school pupils. Greek adolescents consider as drugs those substances that are both illegal and addictive and think of them as being able to combine negative and positive effects at the same time (i.e. death and love, danger
1 Unpublished data of the 1998 nationwide survey “Psychosocial Factors and Health” carried out by the University Mental Health Research Institute.
11 and cease of pain, destruction and joy). This quality, as it was found in the study, is what makes these substances worth to try. In his attempt to form a proposal, the author argues that although legalization would reduce the youth’s indifference in drugs, this should not automatically mean rise of interest in them. Should one hypothesize that this means rise of interest in the short term, one should at the same time hypothesize that in the long term interest would subside, since in every legal substance both negative and positive effects seem to be devalued with time.
Besides the aforementioned scientific studies, however, private initiatives to poll public opinion, that were carried out on behalf of Athenian daily newspapers showed that drugs rank high on the list of social problems for which the public expects immediate governmental intervention.
Moreover, in regard to specific aspects of the problem a daily Athenian newspaper “Eleftherotypia” carried out a small survey on attitudes towards the current legislation on drugs and the possible future amendments among 65 out of 300 Parliamentary Members. A percentage of 65% believed that the repressive policy on drugs that was being followed had not been effective. The vast majority (93%) of the respondents considered drug users as “singular patients” needing sanitary attendance, whereas at the same time 72% believed that prosecution and imprisonment aggravated the drug- problem among addicts. As regards the expansion of substitution treatment, 58% argued in favor of the expansion of substitution treatment with methadone but 46% against the experimental administration of heroin to drug addicts. The experimental administration of heroin as well as the decriminalization of cannabis was supported by almost 24% of the participants (Source: “Eleftherotypia” 16/10/1999).
The proposal of the two governmental members (see also Chapter 1.3.1 Public debates) regarding the controlled administration of substances to which drug addicts were addicted led several professional unions to take a stand on the expansion of substitution treatment. In particular, the Association of Hospital Doctors in Athens and Piraeus opposed the administration of methadone and heroin under medical prescription in public hospitals. According to their view, this would turn them into supporters of addiction maintenance as a way of life and into social control authorities, whereas what was needed, as they stated, was a serious speculation on the causes of addiction. With similar skepticism encountered other professional and social groups this proposal as well, such as psychologists, legal persons, and the Women Confederation of Greece. On the other side, the Association of Doctors in Chania (South Greece) argued for the expansion of substitution treatment with methadone all over Greece and for the administration of heroin in public hospitals. In the same area (Hania), in June 2000, many drug addicts campaigned for the establishment of a new drug therapy center and methadone substitution programme, proposal that was supported by Chania’s mayor, local church authorities and the Organisation Against Drugs (OKANA).
12 1.3.3 Media presentation and image of drug use
The Greek Focal Point since 1999 has started the systematic collection of daily press publications concerning drugs in order to monitor the way, in which the mass media cover and present the phenomenon. Because drugs are considered a multidimensional phenomenon one should expect that the media coverage should refer to all the known factors associated with it. In fact, many aspects are covered (legal, political, scientific, and social) although law enforcement and law violation, as reflected in the police reports presented in the daily press, outnumber all other publications. Thus, emphasis is put mainly at the legal aspect of the phenomenon and the most appropriate source to enlighten the situation and to contribute to its solution are, according to the press, the politicians through their legislative competence. Although not equally, various aspects of the phenomenon are covered by the press. Certain activities developed within the domain of primary and secondary prevention, results from research projects, scientific analyses and views receive occasionally its attention.
From all the different drugs, cannabis and heroin receive most attention, although frequent references to synthetic drugs have also been noticed during the reporting year. However, besides some rare press releases concerning domestic epidemiological data on synthetic drugs, the majority of such press publications are based on data drawn from the foreign news reports. One could infer that although the press is not dealing with a local extended phenomenon, by borrowing foreign data it presents them as being representative for the Greek situation as well. Ignorance of the cultural aspect of the phenomenon by the press has also been ascertained in the past (Tsili 1994), while exploring the drug addict’s image in Greece during the decade 1980-1990. Trying to understand the construction of the initial image of the drug addict in Greece, Tsili traced back in the early 80’s the first press publications on drug addiction. She argued that the articles published then were mainly based on foreign data and bibliography due to lack of national evidence. The press handled the “imported” material by using known journalistic tricks such as exaggeration, misleading and excessive emphasis on the danger associated with drugs. The image of the drug addict during the 80’s was that of a “patient”. Drug addiction had become an issue that differentiated the older from the younger generation, since, as it was presented by the press, it referred mainly to young people, victims of the society and of drug dealers.
Nowadays, the mass media image of drug users resembles to that of the previous decade. Drug addicts are still considered as “patients” and victims, whereas drug dealers as victimizers. Although the blame is put partially on society as a whole, the problem often ceases from being a broader social problem and becomes exclusively a political one. Expansion of drug use is considered to be the result of poor governmental initiative and it is the government that should eliminate the problem. Although “drugs” is a topic that raises permanently a lot of political debates in Greece, the oncoming parliamentary elections in April 2000 intensified the political argumentation around it.
13 Young generations and drug use continue to constitute the core of press argumentation only now the age presented is even younger, since frequent mentioning and analyses of drug circulation within schools, based mainly on individual events, were observed during the reporting year.
Moreover, during the first half of 2000, many newspapers started the mapping of the local open drug scenes in greater Athens. Thus, certain squares downtown or even whole municipalities where characterized as "sinks of drug dealing” promoting the further stigmatization of particular areas.
1.4 Budgets and funding arrangements 1.4.1 Funding at national level In order to overcome the difficulties, that are usually faced in isolating the governmental authorities’ budget on drugs, the Greek Focal Point drew on the estimation of the Ministry of Finance for the realization of the 1999 budget of all involved Ministries and state authorities (Ministry of Finance 1999). Law enforcement data on drugs for 1999 were also asked from the authorities involved in the drug confrontation together with the overall number of law enforcement data and data on their manpower. Since the funding figures refer mostly to the overall budget of each authority, the combination of all the four above-mentioned components is supposed to facilitate the estimation of funds that concern drugs. All data refer to 1999 and funding figures are presented in EURO. Drachma conversion in EURO is calculated at 340.75 drch per EURO (Table 1).
14 Table 1: Public expenditure on drugs
LAW-ENFORCEMENT DATA Police Budget of all national police forces 898.6 millions EURO Police Manpower 45,000 Police Manpower specialising in the fight against drugs 1,200 Frontier- police Manpower (among their main tasks is the fight against the drugs) 2,200 Case files for drug offences established by 7,014 (number of individuals the Police charged: 10,626) Total number of case files established by the Police Data not available Coast Guard Budget of Coast Guard 517.8 millions EURO Coast Guard Manpower 4,691 Case files for drug offences established by the Coast Guard 166 (number of individuals charged: 226) Total number of case files established by the Coast Guard 4,590 Financial and Economic Crimes Office Budget of the Financial and Economic Crimes Office 14 millions EURO Financial and Economic Crimes Office Manpower 1,452 Case files for drug offences established by the Financial and Economic Crimes Office 9 (number of individuals charged: 15) Total number of case files established by the Financial and Economic Crimes Office 518,764
(continued to next page Ê)
15 (continued from previous page È)
Customs Customs budget 1.5 millions EURO Customs Manpower 3,981 Case files for drug offences established by the Customs 35 (number of individuals charged: 43) Total number of case files established by the Customs 7,110 Justice Budget of the Courts 244.4 millions EURO Number of prosecutions for drug offences 10,9101 Total number of prosecutions Data not available Custodial institutions Budget of all custodial institutions 50.2 millions EURO Number of persons imprisoned for drug offences 2,0692 Total number of persons imprisoned 4,2462
PREVENTION AND TREATMENT State budget of prevention centres and prevention programs 3.46 millions EURO Budget of institutions specialising in drug prevention (prevention centres)3 0.9 million EURO State budget of institutions specializing in treating drug addiction4 14.3 millions EURO Budget of Health Expenditures 1424.6 million EURO
RESEARCH AND ACTION AT INTERNATIONAL LEVEL Amount spent on research5 0.13 million EURO Amount spent on international level6 0.09 million EURO
1 Relevant data are not available in the Ministry of Justice. The estimation is made by the Greek Focal Point and is based on the number of individuals charged by all Prosecution Authorities. However, there are cases where charges are pressed against individuals who have not been arrested yet. 2 According to 1991 population census data. 3 The data refer to the state budget. Prevention centres are also subsidised by local authorities (not available data). 4 Data refer to KETHEA and OKANA 1999 public budget. “18 ANO” (Psychiatric Hospital of ATTICA) and the “Drug Dependency Treatment Unit” (Psychiatric Hospital of Thessaloniki) were not included since the Ministry of Health has not provided the relevant data yet.
16 5 Data refer only to OKANA. 6 Data refer to OKANA. Included are UNDCP and participation in interstate projects
Figures concerning, the overall 1999 state expenditures, the Gross Domestic Product and the population are presented below in order to facilitate a proportional estimation of the Greek public expenditure on drugs.
All state expenditures 32.9 million Euros GDP1 111.7 million Euros Population2 10.26 millions
1 1997 data Based on estimations of the Ministry of Finance 3 The data refer to the state budget. Prevention centres are also subsidised by local authorities (not available data).
As regards evaluation and training, isolation of the respective funds is difficult to achieve. Most organisations implement internal or external evaluation projects using part of their total budget, whereas professionals’ training cost in the domain of prevention is included in the total budget of the demand reduction activities. Moreover, data on the state budget regarding national training institutions in the drug field are not available yet.
1.4.2 Geographical differences
An estimation of the geographical distribution of funds and budget on drugs is possible by an overview of the local and regional distribution of competent services. The vast majority of therapeutic services are located in Athens, some are located in Thessaloniki and a proportional smaller number is allocated in other urban areas. Moreover, research on drugs is mainly developed within Athenian institutions and organisations indicating also an unequal funds distribution.
Nevertheless, attempts are being made for a more balanced allocation at the levels of primary and secondary prevention. Conditions of prevention centers’ operation for the first three years provide that up to 50% of their yearly budget should come from local authorities. Further to the first three years the local authorities undertake overall funding of prevention centers. Moreover, among OKANA’s plans is also decentralisation of activities as well as the establishment of new treatment programmes at local and regional level.
17 NEW INFORMATION
Ministerial Decree 33682/27-6-97 : Employers subsidize for new job opportunities creation, for the employment of former drug- addicts, former prisoners and young delinquents, date of adoption: 26/6/1997
Ministerial Decree 33779/15-7-97 : Subsidize of new free-lancers former drug- addicts and former prisoners, date of adoption: 15/7/1997
Law 2776/1999 : Penitentiary Code, date of adoption: 22/12/199, entry into force: 24/12/1999
Ministerial Decree 149020/2-12-99 : Treatment Programme of the Detoxification centers for Drug-dependent Prisoners, date of adoption: 2/12/1999, entry into force: 15/12/1999
Ministerial Decree 3183/12-5-00 : Subjection of proprietary medicine under provisions of Law 1729/87, date of adoption: 12/5/00, entry into force: 24/5/00
Ministerial Decree 3807/31-7-00 : Subjection of substance under the provisions of the law against drugs, date of adoption: 31/7/00
Ministerial Decree 3225/2-10-00 : Subjection of Substances under the provisions of the Law against drugs, date of adoption: 2/10/2000, entry into force: 11/10/2000
OKANA’s Action Plan for the years 2000-2003: The reality about drugs and about the measures of dealing with the drug problem: Prevention-treatment- rehabilitation, issued by OKANA in May 2000.
18 PART II
EPIDEMIOLOGY
19 2. PREVALENCE, PATTERNS AND DEVELOPMENTS IN DRUG USE
2.1 Main developments and emerging trends
2.1.1 Drug use in a changing society
The increase in drug use in the last five years in Greece implies its spread to a wider social group, consisted mainly of young people. Social changes occurring in the eighties decade, such as urbanisation, and immigration might have played a role, in that traditional values became less important to young people that they used to be. Young Greeks were ready to adopt features of entertainment culture and life style from other European countries and the USA, one of them being substance use. In the last few years illicit drug use has taken the form of an epidemic spreading to more socially integrated groups of people, mainly young. Greek drug users in 2000 are not as marginalised as they used to be ten or fifteen years ago and they consume illicit substances mostly for recreational purposes.
Ecstasy was introduced in Greece during the second half of the nineties, with a simultaneous rise in other synthetic substances use. Nevertheless, cannabis users form the largest group of users. The epidemiological profile of cannabis users has changed between 1993 and 1998; data from high-school students surveys show that in 1998, compared to 1993, cannabis users presented less psychopathological characteristics and they were better socialised (Maka et al. 1999).
2.1.2 Social attitudes
Increased social tolerance and increased drug consumption are highly associated. Data from epidemiological surveys conducted in 1998 indicate that the perception of cannabis use as harmful has decreased considerably, mainly after 1993. The percentage of students who consider cannabis experimentation harmless or slightly harmful increased significantly in 1998 (38.8%) compared to 1993 (23.3%), a trend which parallels cannabis use in the 1993-1998 period (Kokkevi et al. 2000b). Similarly, among the 18-24 year olds the percentage of those who perceived the experimentation with cannabis as harmless or slightly harmful increased significantly from 39% in 1984 to 53% in 1998. The leniency that already existed towards use of licit substances such as psychoactive medicines and alcohol, is in 1998 observed towards cannabis use as well (Kokkevi et al. 2000a).
This shift in attitudes forms part of the social context created by the ongoing debate on the discrimination between "soft" and "hard" drugs and the decriminalisation and legalisation of cannabis use mainly instigated by the media.
Among University Students a considerable proportion admitted in 1995 that they did not know whether cannabis was more harmful than cigarette smoking (37.2%) or than alcohol (42.1%), while about 20% regarded cannabis use as
20 less harmful. Around 30% of the students reported that cannabis causes psychological dependence, 17% that it causes physical dependence and 6.9% of students believed that cannabis caused both psychological and physical dependence. About a third of the students were unaware whether cannabis caused any kind of dependence and whether the user could stop at will without needing medical support (Marcelos et al. 1997).
2.1.3 Youth culture
Quantitative and qualitative studies on drug use conducted from 1997 onwards have attempted to draw the picture of the contemporary Greek youth culture in association with drug use.
According to data from the European study "Nightlife in Europe and recreational drug use", conducted in Greece by the University Mental Health Research Institute, young people (18-24 years old) who frequented clubs and parties in Athens reported illicit drug use at higher percentages (41.4%) than people of the same age group from the general population in Athens (31.7%) (Figure 1). Lifetime cannabis use coincided with overall drug use in both the club/party goers and the young people from the general population. Cocaine and ecstasy followed with a prevalence of 10.1% and 9.3%, respectively for the club/party goers, while for the general population the prevalence was remarkably lower (4% for cocaine and 1.3% for ecstasy). This may indicate that ecstasy is strongly associated with recreational places. Among club/party goers, those who reported use of synthetic drugs, seemed to avoid simultaneous use of other licit or illicit substances, being probably better informed than young people from the general population (Kokkevi et al. 1998a).
Figure 1: Drug use by young club/party goers and the general population
% 45 41,4 41,3 40 Club/party goers 18-24 35 31,7 30,7 General population 18-24 30 25 20 15 9,3 10,1 10 4 5 1,3 0 Any Illicit drug Cannabis Ecstasy Cocaine
SOURCE: Kokkevi et al. 1998a
21 Concerning qualitative data derived from the same study, club/party goers report as main reasons for drug use during entertainment the "thorough understanding of music", "relaxation" and "improvement of communication ability". According to the interviewees, experimentation with drugs offers special intellectual and emotional experiences and that "conscious use" helps limiting drug use behaviour to the aforementioned purposes. Consequently, they maintain that use of drugs should be limited to recreational purposes and excessive use, which may entail dependence, or polydrug use should be avoided since such behaviours contradict the recreational character of drug use. It is also reported that the extent of risk of each drug varies; during nightlife entertainment, they tend to use drugs, which they considered less addictive. However, several club/party goers dissociate drug use from entertainment, stressing that some music scenes are developing a movement of drug –free entertainment.
Users of cocaine or synthetic drugs are more likely to engage in “extreme behaviours” (behaviours that involve some kind of risk) and “do crazy or slightly dangerous things” (20% and 53%, respectively) than non-users (2% and 18% respectively) (Siamou et al. 1999).
The consumption of cannabis, synthetics or cocaine tends to be related to petty delinquent behaviours, such as driving a car without a license or shoplifting, to a larger extent than non-use is (Siamou et al. 1999).
Interviews with key persons revealed that young people consume drug before they visit the club. In some clubs there is also dealing besides use; this makes them particularly popular among young users. Use seems to be higher in private open-air parties, as there is protection by the organisers. According to the Police, such parties may be in rare cases organised by drug dealers themselves (Calafat et al. 1998).
2.1.4 Availability of drugs
One of the factors associated with the increase in drug use is increased availability. Epidemiological data from the 1998 surveys indicate that the perception of availability of drugs, and marijuana especially, has changed greatly over the last 15 years. The majority of students in 1998 (67.2%) consider easy or very easy to find cannabis, compared to 39% in 1993 (Kokkevi et al. 2000b).
Similarly, in the general population, the percentage of those who perceive cannabis and heroin as easily available has doubled compared to 1984. In 1998, almost 70% of the total population consider cannabis as easily available, whereas 50% think the same for heroin. In 1984, the respective rates were 34.5% and 26.2%.
On the other hand, the decrease in the prevalence of consumption of psychoactive medicines noted between 1984 and 1998 in the general and
22 school populations, can probably be attributed to their limited availability following the implementation of stricter legislation for their prescription towards the end of the eighties and other policy measures.
New combinations of known drugs appear to be emerging: heroin, cocaine and ecstasy with pharmaceutical drugs (benzodiazepines, tranquilizers) or with LSD and ketamine. Moreover, it seems that heroin or cocaine users experiment with new patterns of use, such as swallowing heroin and cocaine in a cigarette paper.
2.2 Drug use in the population
Illicit drug use in Greece is increasing in prevalence and spreading into wider social groups. In the last two years the increase is mostly evidenced in indirect indicators since the most recent epidemiological surveys are at least two years old.
2.2.1 General population surveys
Trends in the general population drug prevalence exist since 1984 and are based on the nationwide epidemiological surveys that the University of Athens and subsequently the UMHRI have conducted in 1984 and 1998 (Kokkevi and Stefanis 1993; Madianou et al. 1993; Kokkevi et al. 2000a). Both surveys followed the same methodology and very similar questionnaires. The methodology and the main findings were discussed in the 1998 and 1999 National Reports. Below is a brief summary.
Objectives: Ø Prevalence rates, trends, attitudes Samples: Ø Nationwide, multistage, probability, stratified according to the degree of urbanisation Ø Size: 4,297 in 1984 and 3,752 in 1998 Ø Age range: 12-64 years Data collection: Ø Personal interview, based on a structured questionnaire. Main trends: Ø Overall illicit drug use prevalence became three times as high between 1984 and 1998 (from 4% to 12.2%) Ø In 1998, higher percentages were observed in: - men, who had three times the lifetime prevalence compared to women, (18.8% and 6% respectively), and - yound adults, aged 18-35 (22%). Ø Cannabis remained the most popular illicit drug (12.1%).
23 Although illicit drug use remained a male phenomenon during the years, experimentation with illicit drugs or occasional use, seemed to have increased for young women, aged 18-24, much more so than for their male counterparts (Figure 2).
Figure 2: Drug use in the general population by gender (18-24)
Men % 40 1984 35 31,9 1998 30 25 20,2 20 15 13,3 10,1 10 7,1 5 2,5 0 Lifetime Last year Last month
% Women 14 12,1 12 1984 1998 10
8 6,1 6
4 2,5 2,9
2 0,6 0,2 0 Lifetime Last year Last month
SOURCE: University Mental Health Research Institute, 1998
The lifetime prevalence in 1998 compared to 1984 was almost six times as high for women aged 18-24 years (12.1% in 1998, 2.5 in 1984), while for the men of the same age was less than three times as high (31.9 in 1998, 13.3% in 1984). The same ratio was observed in last year's prevalence. Regarding more regular use, differences were even greater: five times as many men reported use in the last month (10.1% in 1998, 2.5% in 1984), while the percentage of women in 1998 was 15 times as high as in 1984.”
24 Women aged 25-35 appeared to have significantly decreased their age at first illicit drug use, by 3.5 years in the last 15 years.
2.2.2 School population surveys
The UMHRI surveys
Epidemiological data on drug prevalence in the student population derive from student population surveys, conducted by the University of Athens and the UMHRI since 1984. Nationwide surveys were conducted in 1984, 1993 and 1998 (Kokkevi et al. 1993; Kokkevi and Stefanis 1994; Kokkevi et al. 2000b). All surveys used the same methodology and similar questionnaires, which are discussed in details in the two previous Reports.
Objectives: Ø Prevalence rates, trends, attitudes Samples: Ø Nationwide, three-stage, stratified, probability Ø Size: 10,814 in 1984, 10,543 in 1993 and 8,557 in 1998 Ø Age range: 13-18 years Data collection: Ø self-completed questionnaire, administered in class by research assistants Main trends: Ø the increasing trend in overall illicit drug use obvious in 1993, compared to 1984, resulted in a sharp increase after 1993, where the percentage of students reporting drug experimentation or use doubled (from 6% in 1993 to 13.7% in 1998. Ø Cannabis, and solvents presented the highest prevalence
The ESPAD study
The ESPAD study in Greece was conducted by the University Mental Health Research Institute (UMHRI) in Autumn 1999. The ESPAD protocol was used and the Greek version of the ESPAD questionnaire.
25 Objectives: Ø Prevalence rates, trends, attitudes Sample: Ø Nationwide stratified, probability Ø Size: 2,205 Ø Age: 16 year olds (born 1983) Data collection: Ø Self-completed questionnaire, administered in class by research assistants Main findings: Ø Overall illicit drug use was reported by 9.7% of students, the majority being cannabis users (lifetime cannabis use= 8.6%). Ecstasy seemed to be the second most popular illicit drug (2.1%), while inhalants use was 14.2% (Figure3). Ø The mean age at first drug use was 15 years. Use of inhalants and amphetamines started at 14 years.
Figure 3: Lifetime drug use in high-school students from the ESPAD Study
Any illicit drugs used 9,7
Cannabis 8,6
Amphetamines 0,9
LSD or other 1,7 hallucinogens
Cocaine 1,4
Ecstasy 2,1
Inhalants 14,2
0 2 4 6 8 10 12 14 16 %
SOURCE: University Mental Health Research Institute, 2000
Finally, a survey carried out in 1994 by the Municipality of Athens in a sample of 153 schools in Athens provided similar results to those from the 1993 school population survey (Fakiolas and Armenakis 1995).
The University of Ioannina school survey
The Medical School of the Univesrity of Ioannina conducted in 1997 an epidemiological survey on drug use in high school students from schools in Athens, Patras (city with approx. 153,000 inhabitants) and Ioannina (city with
26 approx. 57,000. inhabitants). The main aims of the survey were to investigate drug prevalence in high-school students of the country's capital, Athens, and two major Greek cities which combine traditional and modern industrial elements (Dimitriou 2000 unpublished dissertation).
Objectives: Ø Prevalence rates, cross-cities comparison, attitudes Sample: Ø Stratified, probability in 3 Greek cities Ø Size: 2,109 Ø Age range: 16-17 years Data collection: Ø self-completed questionnaire, administered in class by research assistants Main findings: Ø Experience with psychotropic substances (including (Table 2) unprescribed use of tranquillisers) was reported by 8.2% of the students, 13% of boys and 4.3% of girls Ø Boys outnumber girls in both occasional and regular use Ø Cannabis was by far the most popular drug, while other substances presented quite low percentages.
Table 2. Use of psychotropic substances by high-school students: data from the University of Ioannina survey
Total Boys Girls (2,109) (970) (1,139) % % % Lifetime Overall use (at least 8.2 13.0 4.3 once) Occasional use 5.0 7.4 3.1 Regular use 3.2 5.6 1.2 Lifetime overall use Cannabis 7.6 11.9 4.5 Opiates 1.7 1.9 0.9 Cocaine 1.1 1.1 0.9 LSD 0.3 0.7 0.5 Ecstasy 0.4 0.7 0.1 Amphetamines 0.3 0.4 0.3 Tranquilisers 1.2 2.1 0.5
SOURCE: Dimitriou 2000
27 The University students survey
The University of Ioannina conducted a survey on a sample of 1,057 students of in north-western Greece, aiming at investigating the prevalence of cannabis use and attitudes towards it. Data collection was made by an anonymous questionnaire distributed to students. Cannabis experimentation was reported by 17.9% of the students and regular use by 8.7%. A much higher prevalence of lifetime use of cannabis was observed among males, 24.8%, compared to females, 13.5%. In male students the proportion of those regularly using cannabis was 14.4%, while in female students it was much smaller, 5.1% (Marselos et al. 1997).
2.2.3 Geographical distribution of drug use
School population data
The geographical distribution of illicit drug use according to data for the UMHRI school surveys in 1984, 1993 and 1998 are presented in Figure 4.
Figure 4: Geographical distribution of illicit drug use among high-school students
% 20 Athens 18 Thessaloniki 16 Others urban areas 14 Semi-urban/rural areas 12 10 8 6 4 2 0 1984 1993 1998
SOURCE: University Mental Health Research Institute, 1998
Athenian high-school students presented the highest percentages of drug use (18.8%), followed closely by students from Thessaloniki (16.9%). The increase in 1998 compared to 1993 in these two big cities is equally large. Drug use in urban areas (cities with 10,000 inhabitants or more) had also more than doubled in these 5 years (1993-1998), while the increase in semi- urban or rural areas (towns/villages with 2,000-9,999 inhabitants) is somewhat smaller.
The University of Ioannina survey, presented data from three major Greek cities, as discussed previously. According to their data, Athenian high-school
28 students presented the highest overall use (10.7%), but students from Ioannina were very close (9.1%), unlike students from Patras who presented half the Athenian percentage (5.4%) (Figure 5). The same pattern was observed in occasional and regular use.
Figure 5: Use of psychotropic substances by high-school students in three major Greek cities
% 12 10,7 Overall use 10 Occassional use 9,1 Regular use 8 6,4 6 5,4 5,2 4,3 3,9 3,9 4
2 1,5
0 Athens Patras Ioannina
SOURCE: Dimitriou 2000
General population data
Geographical distributions of use between 1984 and 1998 are presented in Figure 6 (Kokkevi and Stefanis 1991; Kokkevi and Stefanis 1994).
Figure 6: Geographical distribution of illicit drug use among the general population
% 20 18 16,7 15,5 16 1984 14 1998 12 9,4 10 9,2
8 6,2 6 4 4 2,8 2,6 2 0 Athens Thessaloniki Other urban areas Semi-urban/rural areas
SOURCE: University Mental Health Research Institute, 1998
29 As seen in Figure 6, the small difference which existed between the prevalence rates of Athens and Thessaloniki in 1984 has almost disappeared in 1998. Other urban and rural areas show equally large increase in these 15 years period.
Prevalence rates on different geographical regions in Greece are expected to come out of an epidemiological survey, which the UMHRI conducted in 1999 in collaboration with the co-ordinating unit OKANA. The sample was representative for each of the 27 prefectures where OKANA Prevention Centres function. The ESPAD protocol and questionnaires were used. Results will be available by the end of the year 2000.
Drug use in the Greek Navy
The Bureau for Prevention and Mental Health of the Greek Navy conducted research on the Navy conscripts, aiming at investigating drug use, attitudes and associated psychopathology among them. According to the conscripts self-reports, 30% had experience with drugs, one fourth of whom reported regular use. Drug use was associated with depressive symptoms but not with age or educational level (Menoutis et al. 1999).
Drug use in the prisons
The first investigation of drug use in prison settings in Greece was conducted in 1995 in two surveys, one by OKANA an the other by the Department of Sociology of the National School of Public Health (NSPH).
The OKANA survey was conducted in two major Greek prisons, aiming at investigating the risk behaviours in imprisoned IVDUs and the prevalence of infectious diseases among them.
In 1995 the overall number of imprisoned individuals for drug offences in Greece was 1,890 (33,2% of all prisoners) (Malliori 2000). The study was conducted in one prison in Athens (Korydallos) and one in Patras (Ag. Stefanos).
Of the 544 drug users who participated, 375 (68.9%) had injected drugs (IDUs) at some time (35% of whom had injected inside prison). Overall drug use in prison (intravenous or not) was reported by 53.7% of the participants (Malliori et al. 1998).
The demographic characteristics of the drug users inmates in the sample of this study are presented in Table 3.
30 Table 3: Demographic characteristics of drug users among prison inmates in 1995
ALL DRUG IDUs NON-IDUs USERS (N=375) (N=169) (N=544) N % N % N % Gender Male 498 (91.5) 338 (90.1) 160 (94.7) Female 46 (8.5) 37 (9.9) 9 (5.3) Mean age (years) 36 35 38 Nationality Greek 489 (90.1) 354 (94.7) 135 (79.9) Other 54 (9.9) 20 (5.3) 34 (20.1) Education Never attended school 16 (2.9) 9 (2.4) 7 (4.1) 1 – 6 years 192 (35.4) 114 (30.5) 78 (46.2) 7 – 12 years 276 (50.8) 207 (55.3) 69 (40.8) > 12 years 59 (10.9) 44 (11.8) 15 (8.9) SOURCE: Malliori et al. 1998.
Most of them were Greeks, especially those who reported intravenous drug use. A large percentage had completed secondary education. Their mean age was 36 years.
The NSPH survey in prisons (Koulierakis et al. 2000) was conducted in 10 Greek prisons on a sample of 861 male inmates. Two hundred and ninety (33.7%) reported drug use at sometime in their lives and 174 (20%) while in prison.
Data from the Treatment Demand Indicator are given for the Psychiatric Hospital of Korydalos prison in Athens. It cannot be clarified wether self- reported drug use refers to use before or during imprisonment, because, although data are collected within the first month of imprisonment in the particular prison, many inmates are transferred from other prisons. In 1999 data are collected for 126 male imprisoned drug users, with mean age 34 years. The main substance of use was heroin for the majority (62.7%), cannabis for 27% and cocaine for 6.3%.
It seems therefore that drug users continue using drugs while in prison, even though drug use is strictly forbidden in prison settings. Sharing needles is apparently very frequent, and is associated with length of imprisonment (Koulierakis et al. 2000).
31 2.2.4 Discussion
The sharp increase in illicit drug use, observed mainly after the first years of the nineties decade, as well as its consequences are discussed in the previous chapter.
The economic growth and "europaisation" of Greece in the nineties affected inevitably the role of women in society, resulting in their penetration in traditionally male domains and the adoption of new social roles, behaviours and attitudes, resembling those of men more and more. Although their development is considered positive and has indeed improved women's position and quality of life, it bears social costs, one of which seems to be substance use, a traditionally male behaviour in Greece. Nevertheless, still more men than women are regular users. In the past few years special attention was given to women drug users in the therapeutic field but not so in the research field. Studies focusing on women are still lacking.
The geographical distribution of drug use has also changed through the years. During the 80's drug use was concentrated in the largest metropolitan areas, Athens and Thessaloniki. In the ninenties, urban and, to a lesser extent, rural areas seem to approach the largest cities in drug use prevalence. Nevertheless, Athens as the capital, continues to be at the top, offering greater opportunities for experimentation and recreational use. It also attracts regular and dependent users, as it combines availability and anonymity, and, for the most motivated ones, therapeutic services.
The observed difference in illicit drug use between 1998 school population surveys and the ESPAD survey, although not statistically significant, should rather be attributed to methodological reasons as all other indicators point at the directions of drug use increase. A subsequent epidemiological survey will clarify the issue.
Social groups, such as army conscripts and prisoners are largely "terra ingognita" in Greece as far as drug research is concerned. The high prevalence among conscripts in the survey of the Navy is an indication of the dimensions of the problem and shows the need for further investigation.
2.3 Problem drug use
Problematic drug use estimates are still lacking in Greece. The main problem is the strict enforcement of the law for the protection of personal data in Greece. The only possible source are the police records, which will possibly be available when the implementation of their new data base will have finished.
Data from indirect indicators of problematic prevalence show that the problem of drug dependence is increasing in Greece.
32 According to data from the Treatment Demand Indicator, the number of applications for therapy has doubled the last 4 years, both in the drug free and in the substitution programmes, while at the same time the mean age of applicants is lowered by 2 years (see section 3.1 for details).
The number of drug related deaths, which presented stability between 1996 and 1998, increased sharply in 1999. Increase is also apparent in the number of arrests for drug related offences.
The patterns of problematic use do not seem to have changed significantly over the last few years. There is an increase in cocaine use as a secondary substance, the main one being still heroin. There is also a shift, for heroin users from injecting to alternative modes of heroin administration, such as sniffing or smoking.
Data from low threshold and street work services (Help Centre of OKANA) show an increased number of new "clients" who either contacted the services themselves or were approached in the framework of street work.
2.3.1 Adolescents and young adults drug users
The profile of Greek adolescent drug users can be drawn by data of the Therapeutic Programme for Adolescent Drug Users and their Families "STROFI", a unit belonging to the therapeutic centre KETHEA and is addressed to adolescent and young adults occasional and dependent users. "STROFI" also offers counselling to adolescent users who are arrested for drug related offences.
The data presented in Figure 7 refer to the adolescents and young adults who requested treatment from "STROFI" in 1998 (N=419) and 1999 (N=450) and they were collected through personal interview (STROFI 1998; STROFI 1999).
33 Figure 7: Characteristics of adolescents and young adults drug users requesting treatment at "STROFI" in 1998-1999
%
79,5 Boys 79,6
18,1 Mean age 18
94,5 Living with family 90,2
48,2 Dropped-out of school 50,9 1998 Mean age of leaving school 15,8 15,9 1999 43,7 Unemployed 42,9 Main substance of abuse 53,2 cannabis 48,9
38,9 heroin 35,3
11,5 tranquilisers 11,6
0 20 40 60 80 100
SOURCE: STROFI, 1998, 1999.
The demographic characteristics of adolescent and young adults users have slightly changed in the last two years; although the majority are still boys, aged around 18 years, smaller percentage live with families, whereas the percentage of school drop-outs has slightly increased. Concerning the main substance of abuse, a slight shift from cannabis to heroin is observed.
2.3.2 Risk behaviours
Risk behaviours among IVDUs, mainly needle sharing, is being studied in Greece since 1991.
n 1991, 75% of the IVDus in Greece reported needle sharing (Kokkevi et al. 1991). In the following year, 1992, the same percentage (75.7%) was reported (Kokkevi et al. 1992), while from another study it was found that 41.8% of IVDUs always clean their equipment before sharing (Malliori et al. 1992) (Table 4).
34 able 4: Needle sharing among Greek IVDUs as reported in different studies in 1991-1993
19911 19922,3 19934 % % % Needle sharing 75 75.72 49.3 (in the last 6 months) Cleaning equipment before sharing 41.83 Using condoms 21.4 21.42 22.5
1 Kokkevi et al. 1991 2 Kokkevi et al. 1992 3 Malliori et al. 1992 4 Malliori et al. 1993
In the beginning of the 90s risk behaviours seemed to remain at high levels. It was in the second part of the 90s decade, that the effect of preventive strategies became visible, as seen in a study conducted in 1998.
That study investigated changes in the Greek IVDUs between 1993 and 1998 and was conducted on a sample of IVDUs who contacted the AIDS Reference Centre of the National School of Public Health in these two reference periods (Kornarou et al. 1999). Their main findings are summarised in Table 5. Needle sharing at least once in lifetime was decreased from 72% in 1993 to 55.9% in 1998, while sharing in the last 6 months remained at the same level. More users seemed to try to clean their equipment (74% in 1998 compared to 33% in 1993), and twice as many users in 1998 (18.9%), compared to 1993 (10%) managed to sterilise them properly. Moreover, increased percentages of users seemed to use condoms in their sexual relationships with occasional partners. The authors conclude that needle sharing is still highly prevalent among intravenous drug users, while they seem to be more careful in their sexual behaviour.
35 Table 5: Changes in the risk behaviours of Greek intravenous drug users between 1993 and 1998
1993 1998 (N=200) (N=243) % % Needle sharing at least once in lifetime 72 55.9 Needle sharing in the last 6 months 39.4 38.6 Cleaning of the equipment 33 74 Proper sterilisation 10 18.9 Condom use (with occasional partner 22.1 64.5
SOURCE: Kornarou et al. 1999
Data from "STROFI" on the risk behaviours among adolescents and young adults are summarised in Figure 8. Injecting and sharing needles was reported by larger percentages of girls than by boys. Girls seem to start injecting at an earlier age than boys. Both genders reported frequent use of condoms at high percentages.
In the prison settings, in 1995 (Malliori et al. 1998), 67% of the inmates who reported injecting in prison admitted needle sharing, while in 1996 (Koulierakis et al. 2000), 83.4% of those admitted to have injected drugs in prison confessed that they shared needles.
Equipment sharing among the Greek drug users presents high prevalence, although syringes are freely purchased in Greece and at a very low price (0.15 EUROs). From recent qualitative data collected by the Focal Point, most pharmacists, wanting to contribute to the reduction of needle sharing, seem to be quite willing to sell syringes to users, sometimes even giving them free of charge.
Nevertheless, even if there is no major problem in syringe obtaining, reports from the users themselves present needle sharing as part of their sub-culture, as an almost ritualistic behaviour, through which they are supposed to prove their trust to each other and ascertain their belonging to the group (Kokkevi et al. 1991).
Data from interviews at therapeutic settings indicate that, in Greece, sharing is mostly limited among relatives, siblings and sexual partners or spouses.
In the prisons where obtaining syringes is extremely difficult, the proportion of users who share is increased.
36 Figure 8: Risk behaviours among adolescent and young adults drug users
Needle sharing
% 70
58,2 60 1998 57,8 1999 47,2 50 45,4
40
30
20
10
0 Boys Girls
Injecting
% 70 59,8 60 1998 51,2 50 1999 40,2 40 37,8
30
20
10
0 Boys Girls
Condom use (with occasional partners)
% 90 80 76,5 1998 1999 70 64,2 62,7 60 55,4 50 40 30 20 10 0 Boys Girls
SOURCE: STROFI, 1999, 2000
37 2.3.3 Dropping-out of treatment
The first study carried out in Greece on drop-out rates and associated factors was recently published by one of the major drug-free treatment agencies in Greece, the Centre of Therapy for Dependent Individuals (KETHEA) (Poulopoulos and Tsiboukli 1999).
The sample consisted of 299 dependent individuals admitted to treatment in 1995-96. Data were collected by personal interview based on the Treatment Demand Protocol.
According to their findings: · The annual drop-out rate was 73.6%. · The majority of clients who dropped-out, did so in the first 30 days of treatment, while those who remained for at least 3 months were more likely to complete treatment. · Past treatment experience increased the risk of dropping-out · Clients over 30 years old were at higher risk for dropping-out compared to their younger counterparts · Current injectors (injecting in the last 30 days) were also more likely to drop-out than those who were not injecting in the month prior to entering treatment.
3. HEALTH CONSEQUENCES
3.1 Drug treatment demand
The implementation of the Drug Treatment Demand indicator in Greece has been discussed in details in all previous National reports. Twelve treatment services available in Greece, including the Methadone Substitution Programme provide data to the Focal Point at the end of each month. Individual data are provided using an anonymous identification code, so that they can be cleared from double-entries at the Focal Point.
In 1999 a new addition was made to the collaborating treatment services, the Alternative Therapeutic Programme (ARGO) of the Psychiatric Hospital of Thessaloniki.
A total of 1,096 clients from all the services participating to the reporting system of the drug treatment demand indicator, requested treatment in 1999, 919 from the drug free programmes and 177 were admitted in the methadone substitution programme. (The methadone substitution programmes include data for admissions and not for treatment demands).
38 3.1.1 Summary of the characteristics of all clients who requested treatment in 1999
Sociodemographic characteristics · The majority of users were men; the ratio of men to women was 5:1 · The mean age of users was 28 years old · Four fifths of them lived in Athens and Thessaloniki · More than half of them had not completed secondary education. Women had higher educational level than men. · Half of them were unemployed, while 1/4 had a full time job. · The majority of them lived with their parents · One tenth of them lived with other dependants
Treatment background and referrals · Half of them had never been previously treated. · More than half of them stated as source of referral themselves or their friends, while one third of users were persuaded by their family
Patterns of use
· Heroine and other opiates were the primary substances of use · The main route of administration of heroine was injection, while the percentage of those who smoked or inhaled had increased · Half of them were polydrug users · The majority had started their drug career with cannabis · The mean initiation age for heroine use was 21 years, while for cannabis was 16 years.
High risk behaviour
· More than 2/3 of users injected currently (last month) and this proportion was increasing according to age. · The mean age of initiation of injecting was 21 years. · One third of current injectors shared needles, more women than men.
Infectious diseases
· One third of them had never been tested for HIV or hepatitis. · Half of those who have been tested were found positive for hepatitis, mainly C, while 2.2% of those tested were found HIV positive.
39 3.1.2 Characteristics of new clients in 1999
Sociodemographic characteristics
In 1999, 608 new clients requested treatment, a number which constitutes 55.6% of all users who requested treatment.
Of these 46.5% stated as source of referral themselves or their friends, while 35.7% of new clients were referred by their family.
· The majority were males (82.8%). · Half of them (51.1%) are between 20-29 years old, while one third were over 30 and 17.4% were adolescents (younger than 19 years old). Their mean age was 26.6 years. · Almost half of them were unemployed (48.8%), only one fourth had a full time job. Most (68.7%) had completed secondary education. · Most of them (73.9%) lived with their parental families (Figure 9).
Figure 9. Sociodemographic characteristics of new clients
Men 82,8 Women 17,2
- 19 years old 17,4 20 - 29 years old 51,1
30 + years old 31,5
Full time job 25
Part time job 13,9
Unemployed 48,8
Students 10
Other 2,2
Parental family 73,9
Alone/with friends 8,2
Spouse/partner 14,5
Other 3,5
0 20 40 60 80 100 %
SOURCE: Greek REITOX Focal Point, 2000
40 Table 6: Characteristics of users starting treatment
All Treatments First Treatment YEAR: 1999 M F T M F T
Treatment cases/demands (Number) 918 175 1093 501 104 605
Sex distr. (%) Male / (%) Female 84% 16% 100% 82.8% 17.2% 100%
Mean age (Years) 29 27 28 27 24.7 26.6
Age distribution <15 0.5 0.6 0.5 0.8 1.0 0.8 15-19 10.1 18.3 11.4 14.8 26.0 16.6
20-24 25.6 26.3 25.7 31.1 31.7 31.4 25-29 20.7 20.0 20.6 20.6 15.4 19.7
30-34 20.7 18.9 20.4 15.6 14.4 15.3
35-39 12.2 9.1 11.7 9.0 6.7 8.6
40-44 7.5 5.7 7.2 6.4 3.8 5.9 45-49 1.9 0.6 1.6 1.2 1.0 1.2
50-54 0.5 0.6 0.5 0.2 0 0.2
55-59 0.2 0 0.2 0.4 0 0.3
60-64 0 0 0 0.0 0 0
³ 65 0 0 0 0.0 0 0
Number of cases with missing 0 0 0 0 0 0 information on age
Injection behaviour ------Currently injecting any drug (%) 70.6 52.0 67.7 64.5 47.1 61.6
Ever injected any drug but not 12.6 22.3 14.1 10.4 18.3 11.8 currently (%)
Ever injected any drug (%) 83.2 74.3 82.0 74.9 65.4 73.4
IV route of ad. Main drug (%) 72.8 54.0 69.8 60.9 40.4 57.4
Main drug (%) – (% IV use) dr. % IV % dr. % IV % dr. % IV % dr. % IV % dr. % IV % dr. % IV %
Opiates (total) 90.1 74.6 86.4 58.3 89.5 72.0 85.8 70.2 79.8 56.0 84.9 71.8 Heroin 89.3 75.1 84.6 58.3 88.6 72.7 85 71.0 79.8 56.0 84.2 72.2
Methadone (any) 0.2 0 0.6 0 0.3 0 0 0 0 0 0 0
Other opiates 0.6 16.7 1.2 0 0.6 14.3 0.8 25.0 0 0 0.7 33.3
Cocaine (total) 1.7 18.7 1.1 0 1.6 16.7 2.4 8.3 1.9 0 2.3 7.1 Cocaine CIH 0 0 0 0 0 0 0 0 0 0 0 0
Crack 0.98 0 0 0 0.9 0 1.6 0 0 0 1.3 0
Stimulants (total) 0.1 0 0 0 0.1 0 0.2 0 0 0 0.2 0
Amphetamines 0 0 0 0 0 0 0 0 0 0 0 0
MDMA and derivates 0.1 0 0 0 0.1 0 0.2 0 0 0 0.2 0 Other stimulants 0 0 0 0 0 0 0 0 0 0 0 0
Hypnot. and sedat. (total) 0.98 0 2.3 0 1.2 0 1.4 0 1.9 0 1.6 0 Barbiturates 0 0 0 0 0 0 0 0 0 0 0 0
Benzidiazepines 0.98 0 1.7 0 1.1 0 1.4 0 1.9 0 1.6 0
Others 0 0 0.6 0 0.1 0 0 0 0 0 0 0
Hallucinogens (total) 0 0 0 0 0 0 0 0 0 0 0 0 LSD 0 0 0 0 0 0 0 0 0 0 0 0
Others 0 0 0 0 0 0 0 0 0 0 0 0
Volatile inhalants (total) 0 0 0 0 0 0 0 0 0 0 0 0
Cannabis (total) 6.3 0 10.3 0 6.9 0 9.6 0 16.3 0 10.7 0
Other substance (total) 0.7 14.3 0 0 0.7 14.3 0.6 33.3 0 0 0.6 33.3 SOURCE: Greek REITOX Focal Point, 2000
41 Patterns of use
· The vast majority of new clients (84.9%) were opiate users (mainly heroin), while cannabis was the primary substance of use for 10.7% of them, cocaine and crack (2.3%), pills (hypnotics and sedatives) (1.6%). · Injection was the most common route of administration for heroin and other opiates (71.8%) (Table 6).
The sociodemographic characteristics and patterns of use of new clients did not differ significantly to those of all clients, which probably implies that the profile of dependent individuals remains practically the same.
3.1.3 Different client profiles in different types of treatment
Treatment demand data can be categorised in those deriving from: a)drug- free programmes and the methadone substitution programme, b) non residential and residential programmes.
Table 7: Number of individuals seeking treatment in different types of treatment during 1999
N % N % Drug-free 919 83.9 Non residential 501 45.7 Substitution * 177 16.1 Residential 595 54.3 Total 1,096 100 1,096 100
* The methadone substitution programme includes data for admissions, not or treatment demands.
SOURCE: Greek REITOX Focal Point, 2000
Client profiles in drug-free and methadone substitution programmes during 1999
Sociodemographic characteristics
· The proportion of women is higher in the substitution programme compared to the drug-free programmes. Mothers and pregnant women have priority to enter the methadone programme. The ratio of men to women for the substitution programme was 3:1, while for drug-free programmes was 6:1. · Age (older than 22) is one of the criteria for admission to the methadone programme, and older (aged 35 and over) applicants are preferred. Therefore, clients from drug-free programmes were younger, the majority (53.4%) between 20-29 years old, while the percentage of clients from the
42 substitution programme who were over 30 years old was much higher (89.8%) (Figure 10).
Figure 10: Age distribution of clients in drug-free and substitution programmes
% 100 89,8 90 Drug-free 80 Substitution 70 60 53,4 50
40 32,3 30 20 14,3 10,2 10 0 0 - 19 years old 20 - 29 years old 30+ years old
SOURCE: Greek REITOX Focal Point, 2000
· More clients from drug-free programmes had a full time job than their counterparts in the substitution programme (24% and 15.3%, respectively), and more clients from the substitution programme were unemployed (66.7% in the substitution programme and 50.4% in the drug-free ones) (Figure 11).
Figure 11: Labour status of clients in drug-free and substitution programmes
% 80
70 Drug-free 66,7
60 Substitution 50,4 50
40
30 24 16,8 20 15,3 14,7 7,1 10 3,4 0 1,7 0 Full time job Part time job Unemployed Students Other
SOURCE: Greek REITOX Focal Point, 2000
43 · The majority of clients from drug-free programmes (74.3%) lived with their parental family. Fewer clients from the substitution programme (44.1%) lived with their family and 27.6% lived with their spouse or partner, while most of them (76.6%) stated as source of referral themselves or their friends.
Patterns of use
· Intravenous heroin use that has led to daily use is another criterion to enter substitution treatment. Therefore, all clients from the substitution programme were heroin users and most of them (76.3%) were current injectors. Fewer clients from drug-free programmes were heroin users (86.4%) and current injectors (66.1%), while the percentage of clients from this type of treatment who reported cannabis as primary substance of use was quite low (8.3%). · Half of the clients from both of types of centres were polydrug users (55.1% in drug-free and 54.8% in the methadone programme). · More clients from drug-free programmes (42.1%) shared needles compared to those from the methadone ones (23.3%); most were women. · In the methadone substitution programme clients are required to be tested for hepatitis and HIV. Not all drug-free programmes have this requirement. Thus, more clients from drug-free programmes had not been tested for hepatitis (39%) or HIV (40,3%), compared to those from the substitution ones, 11.3% for hepatitis and 12.5% for HIV.
Clients from the drug-free programmes and from the substitution one are two different types of population. Their differences are mainly attributed to the strict and very specific criteria that the substitution programme uses (age, drug career, high risk behaviour). Clients from the drug free programmes are younger, live with their parental family, report other drugs as main substances of abuse apart from heroin, share needles more frequently and a large number of them haven’t been tested for hepatitis or HIV. Respectively, clients from the substitution programme are older, live with their spouse or partner, their only substance of abuse is heroin, and few of them (around 10%) have not been tested for hepatitis or HIV. Half of the clients from both types of programmes are polydrug users.
Client profiles in non residential and residential programmes during 1999
Most of the individuals (54.3%) demanded treatment from residential units, while 45.7% from non residential units.
Sociodemographic characteristics
· The ratio of men to women in non residential units was 4:1, while in residential units was 7:1. The proportion of women is higher in non residential units, where the methadone substitution programme is included.
44 · Clients from non residential units were older, 52.9% were over 30 year old, while clients from residential units were younger, 54.5% were between 20 and 29 years old (Figure 12).
Figure 12: Age distribution of clients in non residential and residential programmes
% 70
60 in-patient 54,5 52,9 50 out-patient
40 36,9 32,1 30
20 13,4 10,2 10
0 - 19 years old 20 - 29 years old 30+ years old
SOURCE: Greek REITOX Focal Point, 2000
· Half of the clients from both types of centres were unemployed, while more clients (26.1%) from non residential units had full time job, compared to clients from residential units (19.5%) (Figure 13).
Figure 13: Labour status of clients in non residential and residential programmes
% 60 53,9 52,2 50 in-patient out-patient 40
30 26,1
19,5 19,5 20 13,1
10 6,2 5,6 2,4 1,6 0 Full time job Part time job Unemployed Students Other
SOURCE: Greek REITOX Focal Point, 2000
45 · Most clients from non residential programmes (63.7%) lived with their parental family and 17.8% with their spouse or partner, while the majority of those (74.3%) from residential ones lived also with their parental family. Although they lived with their families most of the clients from both types of treatment stated as source of referral themselves or their friends.
Patterns of use
· More clients from residential units were opiate users (92.1%), current injectors (75.5%) and shared needles (75.5%) than clients from non residential ones (86.4%, 58.5% and 58.5% respectively). On the other hand, more clients from non residential units reported cannabis as primary substance (9.2%) and cocaine (2.4%) than those from residential (5.1% and 1%) respectively (Figure 14).
Figure 14: Primary substance used by clients in non residential and residential programmes
% 100 92,1 90 86,4 80 70 in-patient 60 out-patient 50 40 30 20 9,2 10 5,1 1 2,4 1 1,4 0,2 0 0,7 0,6 0 Heroin and Cannabis Cocaine Sedatives Ectasy Other other opiates
SOURCE: Greek REITOX Focal Point, 2000
· Most of clients from both types of centres were polydrug users (44.9% in non residential and 63.5% in residential programmes), although, more clients from non residential centres (17.8%) reported using only one substance than those from residential ones (9.2%) (Figure 15).
46 Figure 15: Number of substances used by clients in non residential and residential programmes
% 70 63,5
60 in-patient 50 out-patient 44,9 40 37,3
30 27,3
17,8 20 9,2 10
0 One substance Two substances Three substances
SOURCE: Greek REITOX Focal Point, 2000
Almost one third of clients from both types of centres have not been tested for hepatitis or HIV.
Clients from non residential and residential units are two different types of population and their profile is not always determined or influenced by the inclusion of drug-free or substitution programme. Clients from non residential units are older and have a higher proportion of women compared to clients from residential ones. Regarding patterns of use, less clients are heroin users, current injectors and they share needles less frequently compared to those from residential ones. Finally, most clients from all types of treatment are polydrug users, although there is a percentage 17.8% of clients from non residential units who use only one substance.
3.1.4 Treatment demand for cannabis
A small percentage (6.9%) of users stating cannabis as primary substance demanded treatment for cannabis use.
Sociodemographic characteristics
· The majority of cannabis users were young men, below 30 years old. Specifically, one third of them (34.2%) were younger than 20 years old, while the respective percentage for heroin users was 9.9%. · One third of them (28.4%) are students and almost half of them (48%) were high school graduates. Comparing to opiate users, half of them are unemployed and one third (32.8%) were high school graduates (Figure 16). · The majority of cannabis users (86.7%) requested treatment for the first time, while almost half of opiate users (47.4%) have been treated before.
47 · Most of cannabis users (82.7%) lived with their parental family and half of them (55.3%) were persuaded by their family to ask for treatment. Although the majority of opiate users (67.9%) lived with their parental family and 14.1% with their spouse or partner, most of them (61%) have stated as source of referral themselves or friends.
Figure 16: Sociodemographic characteristics of cannabis users
Men 76,3
Women 23,7
- 19 years old 34,2
20 - 29 years old 47,4
30 + years old 18,4
Full time job 20,3
Part time job 12,2
Unemployed 33,8
Students 28,4
Other 5,4
Parental family 82,7
Alone/with friends 10,6
Spouse/partner 5,3
Other 1,3
0 20 40 60 80 100 %
SOURCE: Greek REITOX Focal Point, 2000
Patterns of use
· The mean initiation age for those who demanded treatment for cannabis was 17 years, while for heroin it was 21 years. · Only a small number of them (5.3%) were current injectors, in contrast to opiate users were injectors were the majority (74.4%), in the last 30 days. · Half of the cannabis users (51.3%) took only one substance, while more than half of opiate ones (58%) were polydrug users (Figure 17).
48 ·
Figure 17: Number of substances used by cannabis and opiate users
% 70
58 60 Cannabis users 51,3 opiate users 50
40 31,8 30 27,6 21,1 20 10,2 10
0 One substance Two substances Three substances
SOURCE: Greek REITOX Focal Point, 2000
· The majority of cannabis users (over 75%) have not been tested for HIV or hepatitis, while the one third of opiate users (almost 30%) haven’t been tested for these infectious diseases.
Cannabis users have different characteristics from opiate ones. They are young, one third of them are students, they are staying with their parental family and the majority of them requested treatment for the first time. Their patterns of use differ, as well. The majority were not current injectors and they had not been tested for hepatitis or HIV, and half of them use only one substance. On the other hand, opiate users are older, half of them are unemployed and they had been treated before. The majority of them lived with their parental family, while one sixth live with their spouse or partner. Most of them are current injectors and polydrug users, while one third had not been tested for hepatitis or HIV.
3.1.5 Comparisons of all clients characteristics between 1996-1999
Samples of drug users
After 5 years of implementation of the Treatment Demand Indicator in Greece, it was considered worthwhile to examine the extent to which the profile of the users requesting treatment has changed.
The first two units of the methadone substitution programme started functioning in 1995, when the selection of the first clients was made. In the subsequent years (1996 and 1997) new admissions were made only on gaps
49 caused by drop-outs. In 1998 the methadone substitution programme admitted again a large number of clients for its two new units. Thus the proportional representation of the substitution data in the overall number of clients in the indicator in these five years is as follows: 34% in 1995, 10.1% in 1996, 4.7% in 1997, 43% in 1998 and 16.1% in 1999. Because of this, 1999 data for all treatment units are compared to the 1996 ones, as these two sets of data present the greatest homogeneity (Table 8).
Table 8: Number of individuals demanding treatment in 1996 and 1999
1996 % 1999 % Drug-free programmes 491 89.9 919 83.9 Substitution programme * 55 10.1 177 16.1 Total 546 100 1,096 100
* The methadone substitution programme includes data for admissions, not for treatment demands.
SOURCE: Greek REITOX Focal Point, 2000
· In 1999 twice as many users demanded treatment than 1996 (1,096 and 546, respectively). The increase is apparent in both types of treatment
The sociodemographic characteristics of the two populations are the following: · The number of individuals demanding treatment in drug-free programmes has increased (491 in 1996 and 919 in 1999). Alternative Therapeutic Programme “ARGO”, a drug free programme was added in the reporting system in 1999. · The number of individuals admitted for treatment in substitution programmeshas also increased (55 in 1996 and 177 in 1999). In 1998 two new Methadone Substitution Programmes were added to the two existing ones.
Presentation of comparative data
The sociodemographic characteristics of the two samples of individuals seeking treatment are the following:
Decrease is observed in: · The percentage of men seeking treatment (88.6% in 1996 and 84% in 1999).
50 · The average age of clients (the average age was 30 in 1996, 28.3 in 1999), because the percentage of adolescents seeking treatment is increasing (3,8% in 1996 and 7,8% in 1999), while the percentage of individuals over 30 years old is decreasing (50.5% in 1996 and 41.6% in 1999). · The percentage of elementary graduate (32.1% in 1996 and 24.9% in 1999) · The percentage of drug users who have a full time job (30.6% in 1996 and 22.6% in 1999), while the percentage of students seeking treatment is increasing (1.9% in 1996 and 5.9% in 1999), following the decrease of average age. The majority of drug users is unemployed (52.4% in 1996 and 53.1% in 1999) (Figure 18).
Figure 18: Labour status of clients demanding treatment in 1996 and 1999
% 60 52,4 53,1 50 1996 40 1999 30,6 30 22,6 20 16,5 12,7
10 5,9 1,9 2,4 2 0 Full time job Part time job Unemployed Students Other
SOURCE: Greek REITOX Focal Point, 2000
· Injection of heroin as the common route of administration (83.1% in 1996 and 78% in 1999), while the percentage of those who smoke or inhale heroin is increasing (5.9% in 1996 and 9.2% in 1999). This might be an outcome of the implementation of “safe use” programmes.
Increase is observed in: · The percentage of drug users who live with their parents (62.4% in 1996 and 69.4% in 1999) (Figure 19). · the percentage of dependants who were induced by their family to ask for treatment (12.1% in 1996 and 27.5% in 1999). · Polydrug use (35.8% in 1996 and 55% in 1999). According to qualitative data, the increase of polydrug use is caused by the increase of availability of other substances. Heroin users experiment with various substances to
51 enhance heroin’s effect or use substances which antagonise each other. Cannabis is the primary substance for 7% of users.
Figure 19: Living status of clients demanding treatment in 1996 and 1999
% 80 69,4 70 62,4 60 1996 1999 50 40 30 18 20 13,2 9,2 11,6 10,3 10 5,8 0 Parental family Alone/with friends Spouse/partner Other
SOURCE: Greek REITOX Focal Point, 2000
· Secondary substances like cannabis (49.8% in 1996 and 60% in 1999), pills (28.2% in 1996 and 52.5% in 1999) and cocaine (10.6% in 1996 and 14.8% in 1999), while alcohol use is decreasing (6.8% in 1996 and 2.5% in 1999). · Cannabis as initiation substance of use (68.7% in 1996 and 75.2% in 1999), while average initiation age of substance use (17 years old in 1996 and 16 years old in 1999) and average age of first injecting use (22 years old in 1996 and 21 years old in 1999) is decreasing. · The percentage of current needle sharing (31.1% in 1996 and 38.8% in 1999). According to qualitative data, heroin users, usually, share needles with their partners trying to confirm the close binds between them.
3.2 Drug related mortality
The Greek Focal Point collects on a yearly basis data on deaths caused by acute intoxication (overdose or synergic activity of different drugs). The Third Section of Drugs of the Public Security Directory in the Ministry of Public Order is responsible for the collection of data on drug related deaths, which are published in the Annual Report of the Central Anti-drug Co-ordinating Unit (SODN-EMP). These data are based on the death certificates issued by the forensic laboratories in cases of sudden deaths or after request of the law enforcement authorities for forensic investigation when involvement of drugs
52 in a death case is validly suspected. The Third Section of Drugs maintains that the national coverage of these data is 97%.
The increase in drug related deaths in Greece is particularly obvious in the last 5 years (Figure 20). In 1994 the number of deaths increased by almost 90% compared to 1993. In the period between 1997-1998 the rate of increase showed stabilisation, at around 5% until 1999, when the number of deaths reported was 264, number increased by 8% compared to 1998.
Figure 20: Drug related deaths (1985-1999) N 350
300 265 245 232 250 222
200 176 146 150
79 78 100 72 66 71 56 62 50 28 10 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
SOURCE: Central Antidrug Coordinating Unit, 2000
The demographic characteristics of drug users who died from acute intoxication in the last 5 years are presented on Table 9. As observed, the majority were: · Men, aged between 21-30 years · Athens prefecture residents · Single · Secondary education graduates · Unemployed
Heroin was responsible for the majority of cases.
The main factors contributing to the increase in drug related deaths are the increase in drug use observed in Greece and the ageing population of drug users which implies deterioration in their health. The head of the Help Centre of OKANA remarks that death risk is also increased among relapsed IVDUs, as it has been observed that they use purer heroin and often larger doses when they restart use after having undergone detoxification. Polydrug use
53 and especially the new substances used often result in dangerous mixtures of substances.
Table 9: Characteristics of drug related death cases in 1995-1999
YEARS OF REFERENCE 1995 1996 1997 1998 1999 Certified deaths 176 222 232 245 265 Gender Males 162 202 209 216 245 Females 14 20 23 29 20 Age < 20 years old 7 14 24 33 47 21–30 years old 90 98 102 112 122 > 31 years old 79 110 106 100 96 Geographical Area Athens Prefecture 136 166 166 170 185 Thessaloniki Prefecture 18 25 38 39 31 Other 22 31 28 36 49 Marital Status Single 157 184 96 227 245 Married 15 32 8 16 16 Divorced 4 6 1 2 4 Educational Level Primary education 73 78 36 87 65 Secondary education 30 106 66 143 169 Higher education 6 4 2 3 3 Unknown 66 34 1 12 28 Uneducated 1 Profession Unemployed 99 144 73 175 197 Workers 29 21 15 31 18 Private employees 20 9 6 14 11 Musicians 3 2 Sailors 4 7 1 1 Others 16 35 8 21 31 Prostitutes 4 1 1 1 Civil servants 1 Journalists Scholars 3 1 4 6 Type of drug Heroin 157 213 222 243 263 Morphine 3 1 Psychotropic drugs 13 7 6 1 1 Cocaine 1 3 1 1 Cannabis-Alcohol 2 1 1
SOURCE: Central Anti-drug Coordinative Unit, 2000
54 3.3 Drug related infectious diseases
3.3.1 HIV/AIDS
In Greece, surveillance data for drug related infectious diseases exist only on HIV/AIDS; these data derive from the surveillance of the Centre for the Control of AIDS and STDs (KEEL) of the Ministry of Health.
AIDS prevalence among drug users remains low.
For further details on AIDS, see Chapter 14. Infectious diseases.
3.3.2 Hepatitis B and C
The Greek Focal Point, in 2000, has intensified the efforts to collect data on the prevalence of Hepatitis B and C among drug users. Seventeen sources of information have been identified so far, out of which 13 have already given data for 1999, which are included in the Standard Epidemiological Tables 2000, along with data from special studies. These data are given from each source in aggregated form and have not been checked for double entries; therefore they are presented separately. The Focal Point has already made contacts with sources that offer test results on the issue of individual data collection, using an anonymous code. In this way it is hoped that data could be presented in unified form for the next year.
The sources of information identified are presented in Table 10.
Table 10: Sources and nature of information on Hepatitis B and C and status of collaboration with the Greek FP in 2000
SOURCE HIV – HBV - Offered data in Will offer in HCV 2000 2001 · Nine treatment programmes Five drug-free programmes ü ü Four units of the methadone substitution programme ü 2 2 · Two public laboratories ü ü · Needle-exchange programme ü Not analysed · Prisons ü ü · Two special programmes for women ü 1 · Self-reported data – TDI ü ü ü · Centre for the control of AIDS and STDs HIV ü ü · 3 special studies ü ü
55 According to the test results performed in 1999, hepatitis B prevalence is quite low (lower than 10%), while hepatitis C ranges between 60-90% among Greek drug users.
Under-reporting is obvious in self-reported data.
3.3.3 Tuberculosis
Data on Mantoux test results are offered from the two methadone substitution units in Thessaloniki: 40% of the clients were found Mantoux positive in 1999, all males, the majority (68%) aged over 35 years old.
For further details on hepatitis see also Chapter 14. Infectious diseases.
3.4 Other drug related morbidity
3.4.1 Psychiatric co-morbidity
Several studies on psychiatric co-morbidity have been conducted in the last 5- 6 years in Greece. They mainly investigated the existence of personality disorders and suicide ideation in drug dependent individuals.
Personality disorders among users in treatment
Sample Ø 226 drug dependent clients in 3 therapeutic programmes Data collection Ø psychiatric assessment. Diagnostic instruments used: SCL-90, EuropASI, Composite International Diagnostic Interview (CIDI), Structured Clinical Interview for DSM- IV Axis I Personality Disorders (SCID-II) Main findings Ø 60% of the subjects were diagnosed for at least one personality disorder (PD), most (34%) for antisocial PD Ø Subjects with PD showed, during pre-treatment assessment, higher level of psychopathology, compared to users without PD. Ø Logistic regression analysis showed only PD existence as a significant risk factor for dropping-out of treatment.
Reference: Kokkevi et al. 1998b
56 Personality disorders among users in treatment and in prison
Sample Ø 176 drug users in treatment and prison Data collection Ø Psychiatric assessment. Diagnostic instruments used: Diagnostic Instrument Schedule (DIS) Main findings Ø DSM-III disorders: antisocial (69.3%), anxiety (31.8%), affective (25%), Ø Antisocial personality disorder preceded drug dependence Reference: Kokkevi and Stefanis 1995
Social phobia and depressive symptomatology
Sample Ø 48 drug users requesting treatment Data collection Ø Psychiatric assessment. Diagnostic instruments used: CES-D for depression (Centre for Epidemiological Studies – Depression), CIDI for social phobia Main findings Ø Thirty seven users (77.1%) presented depressive symptomatology (SEC-D>-16) Ø Six users (12.5%) presented symptoms of social phobia Reference: Liappas et al.1998
Suicide attempts among drug dependents
Sample Ø 25 (16 men and 9 women) drug dependent individuals suicide attempters. Ø Nineteen (76%) were heroin dependent, 6 (24%) were dependent on benzodiazepines and anticholinergics. Ø Age range: 15-45 years old. Mean age: 24 years Data collection Ø Personal interview. Main findings Ø Psychiatric assessment (DSM-III R) Ø The majority (56%) were diagnosed as having antisocial personality disorder Ø 20% major depression Ø 16% anxiety disorder Ø 8% psychotic disorder Ø Reasons for the attempt (self-reported) Ø 68% problems in interpersonal relationships Ø 24% financial problems Ø 8% auditory hallucinations Reference: Pertessi et al. 1998
57 Self-destructive behaviour, suicide attempts and cocaine use
Sample Ø 231 drug users in treatment Data collection Ø Psychiatric assessment: DSM-III-R, CES-D Main findings Ø Cocaine users presented higher levels of depression, compared to users of other drugs Ø Suicide attempts were more prevalent in cocaine users than in other drugs users
Reference: Liappas et al.1996
Suicidal behaviour and chronic heroin use
Sample Ø 458 users in substitution treatment Data collection Ø Psychiatric interview Main findings Ø The majority (52%) presented suicidal ideation Ø 28.6% had attempted suicide at least once in their lifetime
Reference: Tsaklakidou et al. 1996
Drug dependence is strongly associated with various aspects of psychopathology. Antisocial Personality Disorders, seem to be highly associated with illicit drug use, probably because both are manifestations of deviancy from social norms.
The high prevalence of suicidal ideation and suicide attempts among drug dependent population could be attributed to the depressive symptomatology diagnosed.
Drugs and driving
A study conducted by the Laboratotry of Forensic Medicine and Toxicology of the University of Athens aimed at identifying the involvement of alcohol and other psychoactive substances in traffic accidents in Greece during 1995- 1997.
Sample Ø 856 drivers and 89 pedestrians, victims of traffic accidents Data collection Ø toxicological analysis following autopsy Main findings Ø 41% of drivers and 19% of pedestrians had blood-alcohol- concentrations over the limit Ø 6% of drivers and pedestrians had consumed some psychoactive substance before the accident
Reference: Athanaselis et al. 1999
58 4. SOCIAL AND LEGAL CORRELATES AND CONSEQUENCES
4.1 Social Problems
4.1.1 Social exclusion
Information presented in previous chapters concerning the Treatment Demand Indicator indicates that the percentage of unemployed users among those who demanded treatment, remains relatively stable in the last few years. In contrast, their educational level has increased.
In a study designed to examine the profile of young marginalised individuals in Athens during 1997/98, 344 drug users were recruited from the street (European Commission 1998).
According to the findings: · Twenty percent were homeless. · Social benefits and charity were reported by around 20% as their main source of income, while illegal activities by 4.2%; 30.8% were living on their parents. · Only 32% had made contact with drug related services and 15% with other social services. · Despite their serious financial, family and, for some, health problems, most of them reported drug use as their major problem.
A recent study designed to investigate the relationship between drug use, criminal behaviour and social exclusion on the basis of the history of a sample of imprisoned drug users, was conducted (Kitsos 2000 unpublished dissertation). Social exclusion was defined through social, economic and demographic characteristics, such as place of residence and employment status before imprisonment, educational level, marital status, as well as their parents’ occupation.
According to the main findings: · The vast majority of these people were severely socially excluded, according to above definition · Social exclusion preceded drug use and involvement with criminal justice system · According to their self-reports, social exclusion is “responsible” for their introduction in marginalised groups who engaged in drug use and criminal acts.
59 4.1.2 Minorities
Until recently, in Greece ethnic minorities were practically non-existent. Today minority groups consist of financial immigrants, refugees, people of Greek origin who were repatriated form countries of the former USSR and ROMS.
A small but increasing number of these people request treatment for drug dependence.
4.1.3 Community problems
Interviews with street workers conducted by the Focal Point, draw the picture of public reactions to users, especially to neighbourhoods where drug use and dealing is common. The reactions of the people who live or work in such places vary greatly; most react negatively, but pity or indifference are also expressed.
The main concerns of the community are petty crime, thefts, committed by users and fights among users. Protests come mainly from shop owners, who maintain that they lose their clientele. Fears for public health are also expressed, because many users are in an wretched physical condition (open wounds, bad odour).
In some places shop-owners have hired private security. In other places people do not protest out of fear for retaliation by the users. There are isolated instances, where inhabitants have created local unions and they protest in an organised and formal way to the Police and the Ministry of Public Order.
4.2 Drug Offences and Drug Related Crime
4.2.1 Arrests and charges
The Focal Point collects on an annual basis data on arrests and charges by the Central Anti-Drug Co-ordinating Unit, of the Ministry of Public Order in aggregated form. According to the law enforcement authorities these data have 100% coverage, since every individual who is arrested or charged is recorded without exception.
Arrested is an individual caught by the police as suspect for a specific offence. An individual is charged when a specific accusation exists, possibly without having been apprehended. Prosecution of an individual implies being arrested, charged and brought to court.
Figure 21 presents the trends in the arrests and charges in the last 6 years. In 1999, 10,902 charges for drug law offences are reported by all law enforcement authorities.
60 The majority of the individuals charged were men (84%) of Greek nationality (90%).
Figure 21: Arrests and charges by the Hellenic Police and charges by the law enforcement authorities (1994-1999)
N Charged by the law 12000 enforcement authorities (1) Arrested by the Hellenic 10000 Police (2)
8000
6000
4000
2000
0 1994 1995 1996 1997 1998 1999
(1) Customs, Ministry of Finance, Coast Guard. (2) No data available for 1998 for arrestees by the Hellenic Police
SOURCE: Hellenic Police and Central Antidrug Coordinating Unit, 2000
The number of arrests reported by the Hellenic Police constitutes steadily around 95% of the total number; for 1999 the Police reported 10,105 arrests, number increased by 67% compared to that of 1997 (in 1998 the Police did not report data on arrests).
Reports from police officials maintain that the police, in accordance with the destigmatisation philosophy of the new laws prioritise arrest of dealers or traffickers of large quantities. The user who possesses small quantities mainly for personal use does not constitute the target of the police. Another reason for this, is that is has been proven that most of these individuals do not attempt to "recruit" new users.
4.2.2 Convictions and imprisonments
The Statistical Service Unit in the Ministry of Justice, collects data from all the Greek judicial authorities and prisons for every case of final court conviction or imprisonment of a drug law offender. The Focal Point receives these data in an aggregated form.
The latest data available for convictions refer to 1996 and for imprisonments to 1997.
61 In 1996 the number of convicted individuals presented increase compared to that of 1995 (1,484 in 1996 and 1,263 in 1995). Convictions for drug use had decreased, while convictions for trafficking had increased.
Figure 22: Individuals imprisoned for drug law offences (1995-1999)
Í 3000
2500 2270 2123 2014 2069 1872 2000 1588 1363 1500 1174 931 999 1000 832 632 662
500
0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997
SOURCE: Statistical Service of the Ministry of Justice, 2000
Individuals imprisoned for drug law offences constitute 50% of the total number of imprisonments. The number of imprisoned individuals remained practically unchanged in 1997 (2,069) compared to 1996 (2.014) (Figure 22).The majority were men (97%).
As seen in Figure 23, most of the imprisoned individuals in 1997 (79.6%), were convicted for trafficking, 12% were convicted for cultivation, while a small percentage (8.4%) were imprisoned for use only.
Figure 23: Imprisoned individuals for drug law offences according to type of offence (1996-1997)
% 90 79,6 76,3 80 1996 70 1997 60 50 40 30 15,3 20 12 8,3 8,4 10 0 Use Trafficking Cultivation
SOURCE: Statistical Service of the Ministry of Justice, 2000
62 This picture is compatible with the latest law amendments, which are more lenient to users, especially dependent users, and stricter to dealers and traffickers.
Health professionals who offer legal assistance to users report that out of those imprisoned for drug use, the majority are simultaneously convicted for other offences, often non- related to drugs. This leaves a small number of individuals who are imprisoned for use only, who are in this situation because they did not show up during trial, either out of fear or because they did not receive a subpoena, not having a permanent residence. The court not having any information on them (for example, if they are dependent on drugs) convicts them "in absence".
4.2.3 Drug related crime
The previous statement reported by health professionals is verified by the findings of a study on criminality among drug dependent people conducted in treatment services and in prison (Kokkevi, et al., 1993). According to the users self-reports 77.6% had been arrested and 57.1% convicted. Arrests and convictions for other than drug offences outnumbered the drug offences. For half of the drug-abusing subjects, involvement in crime predated the start of heroin use. Among the main factors associated with criminality were male gender, polydrug use, unemployment, low educational level, and not injecting heroin as main mode of use.
Results from a follow-up study investigated the relation of imprisonment to further criminality. This research examined a sample of 82 drug-dependent subjects assessed for the first time while in prison and a sample of 123 drug- dependent subjects assessed for the first time while in treatment services. Reassessment took place in the first sample eight years after the first assessment and in the second sample four years after the first assessment. From the sample in prison, 63.6% were found again in prison at the second assessment, whereas only 7.9% of the second sample were in prison (Kokkevi 1992).
Drug related crime in adolescents and young adults
Data derive from “STROFI” unit show that, out of those requested treatment there, the percentage of adolescents and young adults who had been arrested at least once in their lifetime has increased in 1999 compared to 1998 (from 53% to 59.1%). It must be reminded that “STROFI” adolescents having law problems are one of the target groups of “STROFI”. Also increased is the percentage of those who reported multiple arrests (from 6.2% to 11.2% for 6 arrests or more). The age at first arrest is lowered; in 1999 more individuals were arrested at 15 years of age or younger compared to 1998 (23% in 1998 and 31.6% in 1999). The majority (56.8%) in 1999 reported having an income from illegal sources (no data for 1998) (STROFI 1998; STROFI 1999).
63
Pharmacy burglaries
Figure 24 presents the trend in the burglaries of pharmacies reported in the last 10 years.
The decrease in the number of pharmacies being burgled in Greece since 1991 could be attributed to various factors; The low prices and the increased availability of drugs, as well as the intensification of law enforcement measures. (Central Antidrug Coordinating Unit 2000).
Figure 24: Burglaries in pharmacies in Greece (1991-1999)
N 180 160 151 140 114 120 108 100 81 80 57 56 60 47 49 47 40 20 0 1991 1992 1993 1994 1995 1996 1997 1998 1999
SOURCE: Central Antidrug Coordinating Unit, 2000
4.3 Social and economic costs of drug consumption
NO INFORMATION AVAILABLE
5. DRUG MARKETS
5.1 Availability and supply
Greece because of its geogrpahical position in the Balcan peninsula, as well as between the producing countries of Africa and Asia and the consuming ones in Europe, plays an important role in the illegal drug market. A large amount of the quantities seized do not have Greece as their destination.
Drug production may also occur in Greece. In 2000 the police tracked down, for the first time in Greece, a clandestine laboratory where illegal synthetic substances were produced.
64 Most of the quantities of illegal drugs imported in the country comes from Albania and Turkey. Bulgaria and FYROM also constitute important sources of drug import, the former mainly of synthetic drugs. Trafficking from the Netherlands or Moroco is less often.
Regarding drug trafficking inside the country, there is an increased involvement of the Albanian Mafia (Central Antidrug Coordinating Unit 2000). In 1998 91% of the quantities of cannabis seized in Greece came from Albanian dealers, while in 1995 the respective percentage was 68%. Quantities of heroin seized from Albanians in 1998 constituted 75% of all seizures, while in 1995 they constituted 16%.
Turks are trafficking mainly heroin in collaboration with Christian and Muslims of Western Thrace.
Police officials report that Turks drug dealers are easily adaptable to the changes in european law. This is probably the reason that Turkey is considered today the first country in Europe for drug storage and processing.
According to the same officials, Albania and Bulgaria are used for the storage of large quantities of illicit drugs coming from Asia and Africa, because the drug related laws in these countries are very lenient. Greece has the strictest drug related laws of all its neighbouring countries and has signed all the relevant international and European treaties.
5.2 Drug seizures
Data on seizures are collected by the Central Anti-Drug Co-ordinating Unit, of the Ministry of Public Order and sent to the Focal Point in aggregated form.
Decrease is observed in the quantities of heroin and cocaine seized during 1999 (Figure 25).
SOURCE: Central Antidrug Coordinating Unit, 2000
Figure 25: Seizures of heroin, cocaine and herbal cannabis (1991-1999)
N (kg) Cocaine 100000 Heroin Kannabis 10000
1000
100
10
1 1991 1992 1993 1994 1995 1996 1997 1998 1999
65 Specifically, in 1999, 97 kilos of heroin and 45 kilos of cocaine were seized, quantities much reduced compared to the previous year. The law enforcement authorities attribute this decrease to the fact that in 1998 one big seizure (189 kg of cocaine) from the Coast guard increased the total number, while in 1999 there was no seizure equivalent in size.
Seizures of herbal cannabis also present decrease in 1999, from around 17 tons in 1998 to around 14 tons (Figure 25). A big seizure of 5 tons of hashish was made by the Coast Guard on a ship coming from Morocco.
Table 11: Drug seizures in 1999 made by each of the law enforcement authorities
Police Ministry of Finance Coast Total Customs FECO * Guard Cases 7,014 35 5 166 7,220 Cannabis a. Cannabis resin (kg) 18,493 1,015 0,77 35,565 55,843 b. Cannabis herb (kg) 11,616.77 2,215.99 8.738 13,841.50 c. Cannabis oil (kg) 2 0.002 2.002 d. Plants (pieces) 46,198 46,198 Opiates 130,349 13,163 0.002 143,512 Stimulants a. Cocaine (kg) 44.864 0.226 0.429 0.089 45.608 b. Amphetamines (kg) 1.38 1.38 (pills) 175,000 175,000 c. Ecstasy 2,699 116 2,815 Other psychotropics a. L.S.D. (doses) 210 210 b. Tranquillizers (kg) 80,210 80,210 (pills) 41,668 71 272 42,011 c. Barbiturates (pills) 32 32
* Financial and Economics Crimes Office
SOURCE: Central Anti-drug Coordinative Unit, 2000
As seen in Table 11, the larger quantities of drug seized are made by the police. Large quantities are also seized by the Customs and the Coast Guard, as according to the annual report of the Central Anti-drug Coordinative Unit,
66 around 65% of trafficking of cocaine and cannabis is made by sea, in contrast to heroin (3% by sea) (Central Anti-drug Coordinative Unit, 2000).
5.2.1 New trends in drug trafficking
According to data derived from the Law enforcement authorities, new trends in drug trafficking are observed in 1999.
Production of drugs was revealed for the first time in Greece in 2000. In spring 2000, police seized a large amount of precursor substances and amphetamines (26.159 pills) produced in a clandestine laboratory of a local pharmaceutical industry situated in central Greece. This resulted in a sharp increase in amphetamines seizures (30.106 pills) compared to the absence of seizures of the substance in 1999 and the very small amount (5 pills) of seizures in 1998.
The Coast Guard reported a new method of transporting cocaine and heroin through the ships which transfer illegal immigrants.
The Police reports ordinary mail (in small parcels) as a new method of heroin trafficking from Turkey to Greece.
Additional information worth mentioning concerns the pharmaceutical substance “rohypnol”: according to the information sent by the General Chemical Laboratory and Financial Economic Crimes Office, 175.000 pills of Rohypnol 2mg (chemical name: flunitrazepam) were seized in Greece while being in transit from the Netherlands to Egypt .
5.3 Price and purity
Information on price and purity is given by the Hellenic Police. Samples of the quantities of each drug seized are sent to the National Chemical Laboratory for analysis and the police information is based on these analyses.
For 1999 the purity ranged between 60-70% for cannabis, 40-60% for cocaine and 20-30% for heroin.
The retail and trafficking prices of various drugs is presented in Table 12.
67 Table 12: Retail and trafficking drug prices in 1999 (in EURO)
Retail Trafficking Cannabis resin 2.91- 5.82 /gr 1,450 – 2,330 /kg Cannabis leaves 1.45 – 2.91 /gr 291.30 – 582.60 /kg Heroin 52.43 – 58.26 /gr 14,565 – 29,130 /kg Amphetamines 3.50 - 4.40 /pill 2.33 - 2.91 /pill Cocaine 58.30 – 87.40 /gr 29,130 – 58,260 /kg LSD 5.80 – 8.73 /pill 2.91 – 4.36 /pill Ecstasy 11.65 – 23.30 /pill 5.82 – 8.73 /pill
SOURCE: Hellenic Police, 2000
Cocaine is by far the most expensive drug, followed by heroin. Cannabis prices are very low, when a packet of tobacco cigarettes costs between 1.7 and 3.50 EURO in Greece.
6. T RENDS PER DRUG
6.1 Cannabis
Cannabis is the most popular illicit drug according to data from the 1998 general and school population surveys. Among the student population, the lifetime prevalence has doubled in 1998 compared to 1993 (4.6% and 12.6%, respectively). In the general population (ages 12-64) cannabis prevalence is 12.2% in 1998, that is three times higher than what it was in 1984, when the previous nationwide survey in the general population was conducted. Men are three times as many as women (18.8% and 6%, respectively). Young adults (18-35 year olds) present the highest prevalence (around 22%).
Of the students and the young adults aged 18-24 years who report cannabis use: · the majority report use with friends of the same age or their girl/boyfriend. · 22% of students have used cannabis during football matches and 30% at school. · young adults prefer using cannabis at home, while high-school students prefer open spaces, probably because they live with their parents.
Data from the treatment demand indicator in 1999 show that cannabis is for most users (75%) the first substance they ever used, but only 6.9% report cannabis as the main substance of abuse. Compared to 1996, in 1999 heroin users who report cannabis as the secondary substance of abuse have increased (from 49.8% to 60%). (Treatment demand data on users requesting treatment for cannabis use are presented in Chapter 3.1 Treatment demand for cannabis)
68 Contrary to the treatment demand indicator data, the majority of adolescent and young adult users who request treatment at “STROFI” in 1999 (see Chapter 2.3, Figure 7) report cannabis as their main substance of abuse (48.9%) (STROFI 1999).
6.2 Synthetic drugs
Ecstasy use is reported by 2.1% of high-school students and 0.2% by people aged 12-64. Its use is more popular among club/party goers (12.5%), while its prevalence among dependent individuals requesting treatment is 1.6%.
Out of the students ecstasy users, 35% have used it during football matches and 27% at school.
Students and young adults (18-24 years) consume ecstasy mostly in rave parties.
As seen in Figure 26, adolescents who frequent clubs and parties are better informed on the risks of simultaneous use of ecstasy and other substances than high-school students in general.
Figure 26: Simultaneous use of ecstasy and other substances by high-school students and club/party goers
% 100
90 83,3 Ecstasy users among 77,1 club/party goers 17-19 80 Ecstasy users among school 70 population 17-19 60 50 41,2 40
30
20 13,3 10 6,7 6,7 0 Ecstasy with cannabis Ecstasy with medicinal Ecstasy with alcohol and illicit drugs
SOURCE: Kokkevi et al. 1998
The use of hallucinogens (mainly LSD) has doubled between 1993 and 1998 in the school population (1.3% in 1993 and 3% in 1998), while in the general
69 population, use of hallucinogens is low (0.9%).
New information on synthetic drugs:
Use of new synthetic drugs, such as 4-MTA, or other synthetic drugs producing stimulating or hallucinogenic effects, such as “poppers” (nitrites), “crystal meth” (methamphetamine), ketamine and GHB seem to be limited. This information is based exclusively on the views of the users approaching therapeutic programmes and it is not confirmed by data from other sources, such as seizures or researches. On the contrary, the increase in ketamine use is verified by various sources (General Chemical laboratory, qualitative research data).
For additional information on synthetic drugs see Chapter 2.1 Youth culture.
6.3 Heroin/opiates
Heroin prevalence among the general and the school population is very low (0.4% and 1.1%, respectively). Insignificant changes have been observed through the years.
Heroin prevalence is also low among club/party goers, and is mainly used by those aged 25-29 years old who are multi-drug users.
On the contrary, among drug dependent individuals, information from treatment demand data indicate that heroin continues to prevail as the main substance of abuse (89.1% among individuals seeking treatment in 1999).
6.4 Cocaine
See Chapter 13. Cocaine and base/crack cocaine.
6.5 Multiple use
Use of more than one substance was reported by 7.3% respondents from the general population and 2.3% form the student population.
Multiple use among users who requested treatment seems to have increased between 1996 and 1999, as seen in Figure 27.
70 Figure 27: Number of substances used by clients requesting treatment in 1996 and 1999
% 60 55
50 1996 1999 38,7 40 35,8 31,8
30 25,5
20 13,1 10
0 One substance Two substances Three substances
SOURCE: Greek REITOX Focal Point, 2000.
More than half of the 1999 sample of users (55%) report use of three substances compared to 35.8% in 1996. The percentage of users who use one substance only decreases accordingly.
Alcohol and drugs
Data from the general population surveys indicate that in 1998 compared to 1984, alcohol consumption among drug users has decreased, both in terms of frequency and heaviness (Figure 28)(Terzidou et al. 2000).
Figure 28: Very frequent alcohol consumption among drug users and non-users between 1984 and 1998
% 60 50 50 1984 42 1998 40 33,8
30 27 1 20 15,6 16 10,610,1 10 10 6,5 2,4 4,1 0 Non users Users Non users Users Non users Users
SOURCE: UMHRI, 2000
71 Although drug users continue to drink more than non-users, differences between illicit drug users and non-users seem to be decreasing in the last 15 years. This is probably related to the fact that through the years the group of users becomes larger and includes more socially integrated population groups.
7. CONCLUSIONS
7.1 Consistency between indicators
Common conclusion from all epidemiological indicators, direct and indirect, is the increase in drug use in Greece in the last years. Increase in availability is also apparent both in self-reports of recreational and dependent users and in data deriving from the law enforcement authorities. The decrease in pharmacies burglaries is another evidence for increased availability of drugs.
Increase resulted in the geographical spread of use; although Athens and Thessaloniki remain the first areas in drug use prevalence, urban and rural areas are closely following, as survey findings indicate. This is also evidenced by the number of drug related deaths, according to which increased rates of deaths due to acute intoxications are seen in urban and rural areas. It must be noted, though, that the increase in deaths in the non-metropolitan areas is also due to the increased sensitisation and alertness of the police in the last years.
Quantitative and qualitative data conclude that drugs in the second half of the 90s decade, are mainly consumed for recreational purposes, increasingly so, following the picture prevalent in other European countries.
In contrast, drug dependence does not seem to have radically changed in the last few years. Nevertheless, increased number of drug users seek professional help, probably as a result of the enhanced sensitisation and awareness of users. Increased number of women demand treatment, as the representation of women in drug use in general is increasing.
Although risk behaviours, particularly needle sharing, are quite prevalent among dependent users, HIV infection remains low. This is not the case, though, for hepatitis, an infection spread to the majority of intravenous drug users.
Criminality and drug use seem to be highly associated; this may by partly attributed to the antisocial personality disorder common among drug dependent users, but mostly to the nature of the behaviour which necessitates involvement in criminal acts to ensure its continuation.
72 7.2 Implications for policy and interventions
The first priority in prevention should be to address young people in the settings they seem to consume drugs mainly recreational settings. The implementation of specialised programmes is seriously considered by the state.
Other population sub-groups need special attention as well; minorities, a relatively new kind of cultural group in Greece, are apparently greatly involved both in drug use and trafficking. The situation and the needs of this population need to be studied and preventive or therapeutic programmes need to be planned and adjusted to their characteristics or needs.
Socially excluded drug users form another “dark area” regarding research and action taking. Research findings from the prison settings form only small indications of the extent of the problem among inmates. Apparently, forbidding use in prison by law has only resulted in “burying” an existing and serious problem.
Drug use should seize to be considered as a homogeneous phenomenon. Different drugs are consumed by different sub-groups and in different conditions. Cannabis has become so widespread that specific interventions may be needed. Use of synthetic drugs or new combinations have not been investigated thoroughly, neither have the new patterns of use.
Another major priority for preventive strategies in Greece is safe use. It is true that preventive efforts have been intensified in the last years, but the alarming data on deaths and hepatitis require urgent measures. Therapy and vaccination for infectious diseases is also imperative and should be introduced to all types of therapeutic programmes.
7.3 Methodological limitations and data quality
The law enforcement authorities have improved the quality of data they give to the Focal Point. This is probably the result of their own involvement in European groups. Still, though, their data cannot provide all the information needed for a full understanding of the situation in the country.
Therapeutic programmes seem to have realising more and more the importance of collective effort and common collaboration to data gathering and feedback provision.
Obvious as it may be that research has been increasing in Greece, it is still fragmentary. The various studies conducted are not part of a centralised planning and consequently are not planned to investigate identified needs or answer specific questions.
73 The long overdue estimation of social and economic costs of drug use should be included in policy-makers agenda. It would be most useful for all parties to have an idea on this dimension of the problems as well.
Finally, the quality of information and data is expected to improve through evaluation. After several years of implementation of efforts in the areas of research, prevention, and therapy, evaluation is a need, which all parties have more or less realised. Specific evaluation strategies are being implemented. The results are eagerly expected and will be welcomed by all professionals.
74 PART III
DEMAND REDUCTION INTERVENTIONS
75 8. STRATEGIES IN DEMAND REDUCTION AT NATIONAL LEVEL
8.1 Major strategies and activities
Following the proliferation of the prevention and the therapeutic programmes during the last three years, emphasis was given in 2000 not only on the development of new services but mainly on the promotion of quality assurance in the demand reduction field. Within this framework, combined efforts from policy makers and professionals working in the drugs field focused on acknowledging the gaps at the provision of services in terms of both quantity and quality as well as on taking action to respond to the drug users’ needs more effectively.
Thus, on the grounds of the necessity to support the existing structures along with envisaging new programmes adjusted to the current needs, the major strategies of the national demand reduction policy for the year 2000 were aiming at:
· Ensuring the development and effectiveness of the existing prevention programmes · Continuing the establishment of new prevention centres nationally · Expanding therapeutic programmes (i.e. drug-free, substitution, low- threshold programmes) in regions where treatment options are lacking · Establishing methadone maintenance programmes · Creating specialized services for drug users with special needs, such as adolescents, prisoners, culturally different people, hidden populations · Providing ex-drug users with further opportunities for their social re- integration and vocational rehabilitation · Consolidating systematic and effective collaboration of all the responsible agencies in order to promote professionals’ training and programmes’ evaluation.
At primary prevention level, the establishment of nine new prevention centres in 2000 resulted to their increase up to fifty-one centres overall (Annex I-Table I), while seven more are foreseen to be inaugurated until the end of the year. Students as well as their teachers and parents prevail as the main target groups of preventive programmes, but at the same time more emphasis was given to the community agents’ involvement in preventive activities. Moreover, health promotion programmes at secondary schools, which take place under the initiative of the Ministry of Education, were also increased.
An initiative of high importance was the evaluation study on the difficulties and needs of the forty prevention centres, which had been established by the Organization Against Drugs (OKANA) in co-operation with the local authorities until December 1999. The study was conducted by the OKANA and the Greek REITOX Focal Point from December 1999 to February 2000. Adopting promotion of quality at the prevention field as an ultimate goal, the results from this study constituted the basis for a concrete policy to be planned in order to
76 overcome the existing difficulties and to cover the prevention agents’ scientific and educational needs more effectively.
Based on research data and clinical experience, new therapeutic and harm reduction services were planned during 2000. The establishment of these services is foreseen to cover the demand for treatment agencies at local and regional level as well as to respond to the needs of specific groups of drug users. Within this framework, a methadone maintenance unit has already been inaugurated in Athens, many of the existing regional therapeutic programmes have expanded their services to adolescents drug users and they have implemented street-work interventions at the local communities. Apart from these initial steps already made to expand the network of therapeutic services nationwide, the majority of the new programmes are envisaged to be established within the period 2001-2003.
The vocational and social rehabilitation of former drug users was another area of intervention on which emphasis was laid. Having being initiated in 1998- 1999, the development and implementation of vocational training programmes was systematized in 2000. Moreover, a plethora of creative and cultural events was organized, under the scope of ex-drug users’ social integration within the wider community.
Training of professionals was also reinforced through the publication of new educational materials, the organization of seminars and conferences on a more systematic basis and the co-ordination of meetings to exchange experience and opinions. The main themes of these training programmes concerned effective methods of intervention in different scopes of work (i.e. prevention at the primary education, drug counselling, street-work programmes) as well as the promotion of an evaluation culture in the demand reduction field.
8.2 Approaches and new developments
Taking into consideration that drug use and drug-related problems call for multi- level strategies adjusted to the local social context and the different needs of drug users, developments at primary, secondary and tertiary prevention level were as follows:
Primary Prevention Interventions
OKANA continued the establishment of new prevention centres at the local and regional level, which are established progressively since 1996 (Figure 29).
77 Figure 29: Prevention centres established by the OKANA per year of inauguration
% 60
50 45,1
40
30 21,6 20 17,6 13,7
10 2 0 1996 1997 1998 1999 2000
SOURCE: OKANA, 2000
In 1999-2000, special emphasis was given on the implementation of prevention programmes to primary education students and to youth outside schools. In this context, new educational materials were published and systematic training of professionals on these particular type of interventions was further developed.
Secondary Prevention Interventions
The main trend in the therapeutic field in 1999-2000 was the expansion of new treatment programmes at the local level and the provision of new services that cover the particular needs of specific groups of drug users.
In 1999, a specialised therapeutic programme for addicted mothers that enable them to enter into treatment while their children will also be taken care of by specialised staff at a nursery addressed to them, started to fully operate within the premises of the KETHEA therapeutic community “ITHAKI”.
“ITHAKI” also developed the Support Centre for Prisoners and Discharged Prisoners in Thessaloniki. The centre runs two supportive structures, both within and outside the prison setting, aiming at harm reduction, enhancing motivation to treatment, rehabilitation and social reintegration.
Many treatment units addressing adults started in 1999 to offer their services to adolescents drug users, as an attempt to meet the increased needs of this population and in order to cover the lack of treatment programmes for adolescents at the local and the regional level. In this context, the “ITHAKI” (Macedonia), “ARIADNI” (Crete) and “EXODOS” (Central Greece) therapeutic programmes of KETHEA provided counselling and therapy to adolescents drug users and to their families. The creation of specialised therapeutic programmes for adolescents at these regions as well as at other towns in the country is one of the main future plans of national drug policy. Innovative interventions have
78 already taken place regarding counselling and therapy of juvenile delinquents, in an attempt to prevent increase of deviant behaviour and of other psychosocial problems.
Streetwork initiatives have also been expanded at the local level. Professionals working at the existing therapeutic programmes as well as drug users who are under treatment implemented several streetwork interventions with the aim to inform drug users about infectious diseases and other risks from drug abuse and to motivate them for drug treatment. Outreach work is foreseen to be expanded in Thessaloniki in the near future, with the inauguration of an well- organized law threshold service there by OKANA.
Based on the need to further expand therapeutic programmes at local level, OKANA has planned in 2000 the inauguration of new treatment services in the near future. These will consist of both drug-free and methadone substitution / maintenance services. In particular, three substitution and four maintenance units as well as two drug-free programmes are planned to be established in order to cover local needs nationwide. The first methadone maintenance unit has already started to operate in Athens, since July 2000.
Tertiary Prevention Interventions
Since 1998, the promotion of after-care and rehabilitation programmes as well as the provision of vocational opportunities to former drug users have become an issue of high importance. These developments emanated in order to meet the social needs of ex-addicts and thus to prevent relapses and to reinforce the therapeutic outcome of treatment programmes. Within this framework, treatment agencies and the Ministry of Labour and Social Welfare continued in the next two years to offer innovative social and vocational rehabilitation interventions for ex-addicts.
In 1999, the KETHEA therapeutic programme “DIAVASSI” developed a Work Club aiming at assisting former drug users in their pursuing for a job and at supporting those who work already. The Work Club carries out several activities ranging from organizing seminars on working issues to coming in touch and sensitizing employers about former drug users in search of a job.
In 2000, vocational training and social rehabilitation centres were also developed by OKANA for ex-addicts who complete substitution treatment as well as for long-term substitution clients.
The Ministry of Labour and Social Welfare continued in 2000, in collaboration with the Employment Organization of Labour Force, to provide subsidized vacancies to ex-addicts and discharged prisoners in order for them to work at the private sector. Financial assistance to those belonging in these groups who want to run their own business has been, also, offered.
79 Socio-cultural developments and developments in public opinion
The lay public appears to highly support prevention and therapeutic initiatives. This is evident from the fact that local communities encourage and in many cases demand the development of new services, which will either prevent or combat drug use at the local population. Moreover, the creation of many volunteer groups at the local and regional level aiming at contributing to drug prevention proves that community agents have become strongly sensitized in drug issues. The Mass Media, especially the local Press, have also been involved in informing the lay public on the several developments in the demand reduction field, and thus play an important role in sensitizing the general population. Another development in the socio-cultural context regarding demand reduction is the implementation of an increased number of cultural activities at the local communities, which in many cases are organized by the local authorities.
Meetings and conferences in 1999-2000
Along with these initiatives, demand reduction programmes and research agencies organized several meetings and conferences on drug-related issues. Most of them are listed below:
1. Meeting on “Evaluation of the Therapy organizations related to drug addiction: Policy and Implementation”, Athens, 11 November 1999, organized by KETHEA under the auspices of the Ministry of Health and Social Welfare.
2. Press conference organized by the University Mental Health Research Institute and OKANA in Athens on 22 November 1999, on the occasion of the presentation of the EMCDDA 1999 Annual Report for Drugs and Drug Addiction.
3. Meeting on “Health in Prisons – Facing the Drug Problem”, Athens, 27 November 1999, within the framework of the programme “Health in Prisons”, organized by the European Regional Office of the World Association of Health in co-operation with OKANA
4. Meeting on “Counselling and Psychosocial Support in the Prevention and Confrontation of AIDS”, Athens, 11 December 1999, organized by the Greek Counselling Association in co-operation with the Greek Help Line & the Councelling Centre of AIDS
5. Meeting on “The role of the Local Authority in the Promotion of Health”, Thessaloniki, 24 May 2000, organized by the Prevention Centre “PYXIDA” in co-operation with OKANA.
6. Open Day Session on “Special Populations in Drug Addiction: The necessity for a new approach”, Athens, 29 May 2000, organized by KETHEA under the auspices of the Ministry of Health and Social Welfare.
80 7. Press Conference organized by the University Mental Health Research Institute in Athens on 3 July 2000, on the occasion of the presentation of the Greek Annual Report for Drugs and Drug Addiction in Greece.
8. Meeting on “Addictions: Consequences and New Approaches”, Athens, 18 September 2000, organized by KETHEA and the Addiction Technology Transfer Center – University of California San Diego, under the auspices of the Ministry of Health and Social Welfare.
9. Meeting on “Refugees and social exclusion”, Athens, 16 October 2000, organized by Karitas Hellas under the auspices of Caritas Europa.
10. 4th Panhellenic Meeting of Prevention Agencies, Heraklion, Crete, 24-27 October 2000, organized by the Prevention Centre of Heraklion (KESAN), under the auspices of the Ministry of Public Health and Social Welfare, the Ministry of Education and Religious Affairs, the Municipality of Heraklion and the Organization Against Drugs (OKANA).
New research findings
In 1999-2000 research in demand reduction issues was also developed. Research regarding policy on drugs shows that drug users and addicted persons benefit from a meticulously structured institutional framework and the respective therapeutic infrastructure (Mavris et al 1999). In addition, the implementation of a comprehensive multidisciplinary policy in the field of drug abuse including primary, secondary and tertiary prevention proves to be beneficial for the target-population (Malliori et al. 1999). For instance, in secondary prevention the expansion of all types of therapeutic approaches appears to motivate more addicts to apply for treatment. Moreover, the establishment of the OKANA First Aid and Support Center with its Mobile Unit, the street-work programme and the other harm reduction interventions has shown to reduce the risk factors at both the individual and the public level.
Regarding research findings on drug use prevention and treatment, it has been suggested that research data are exploited to a limited extent in terms of planning interventions in this field. This seems to be attributed to the lack of communication between researchers and practitioners as well as between researchers and policy makers (Kokkevi 1999). Studies conducted in health services for drug addicts show that the promotion of health attitudes raises drug users’ awareness on mental health and detoxification issues. (Papoutsopoulou et al. 1999). Evaluation studies on training programmes addressing health professionals suggest the following: a. health professionals have difficulties in integrating new knowledge and in incorporating it into practice, and b. there are no clear boundaries between the role of each professional working in the drug prevention field (Mostriou et al. 1999).
Recent research studies on adolescents’ treatment indicate that the main focus of interventions should be on the involvement of the whole family, the nuclear
81 and sometimes the extended one, as well as to the adolescents’ education (Kalarritis 1999). Other studies regarding juvenile delinquents demonstrate that only 4% of the adolescents who are in correctional institutions are provided with some kind of support from social services (Aristoteleion University of Thessaloniki 2000). Findings of this study indicate that the most effective policy against criminal behaviour consists of a more comprehensive social policy.
9. INTERVENTION AREAS
9.1 Primary Prevention
9.1.1 Infancy and family
Although interventions in pre-school children are still limited in Greece – due to the fact that prevention policy is focused on primary and secondary school children – family programmes are continuously expanding. The further promotion of interventions aiming at parents appears to result not only from the establishment of new prevention centres, but mainly from the increased sensitization of parents to participate in such programmes.
One of the main evaluation outcomes of the previous years’ family programmes nationwide was most participants’ willing to further attend them in the future and to sensitize other parents to participate, too. Thus, this positive effect of previous interventions contributed for the overall number of parents who attended drug prevention programmes in 1999 (1.813 persons) to be doubled in comparison to 1998 data (930 persons). Stability of participation and fewer dropouts, also, characterized family interventions in 1999.
Moreover, current data show that some practical difficulties of previous years’ interventions, such as the limited involvement of fathers in prevention programmes and the lack of attendance by parents with pre-school or primary school children, tend to be resolved in a considerable number of prevention centres. For example, the Prevention Centre of the Municipality of Nikaia (Athens) reported an increase in fathers’ participation in the family seminars from 2% in 1998 to 13% in 1999.
The objectives of all programmes aiming at parents, independently of the age of their children, still focus on the personal development and support of their role rather than on information about drugs. Priority is, thus, given to the expression of their feelings, to the improvement of their relations with their children and partners and to the development of communicative skills.
Process evaluation of the one-year “Sensitization Programme for Parents” implemented by the Prevention Centre of the Municipality of Alimos (Athens) showed that training in communication skills was considered by the majority of the participants as the most important aspect of the programme. Also, role-playing and provision of specific examples were evaluated as the most effective techniques. These were also the results of the programme entitled “Intervention in the family”, which started to be implemented in January
82 1999 by the Prevention Centre of the Prefecture of Thessaloniki “ELPIDA”. In particular, 91.3% of the 125 participants regarded the alternative ways of communication to be the best part of the programme, while 98.7% stated that experiential training and role-playing kept their interest throughout the seminars.
The Drug Dependence Prevention and Health Promotion Centre "PYXIDA" (Thessaloniki) implements parents' schools since May 1998 aiming at informing parents about the developmental stages of children and the factors that contribute to a healthy psychosocial development as well as at supporting them to their parental role. Based on an evaluation questionnaire administered to the 336 parents who participated in the programme in 1999, results showed that the objectives of the parents’ schools were achieved to a high degree (Table 13). Moreover, those who systematically attended the programme created a group of volunteers, which play an important role in sensitizing other parents in the community.
Table 13: Evaluation results of the “Parents’ School” programme of the Prevention Centre “PYXIDA”
Parents with children in: Parents’ Replies Infancy School age Adolescence % % % Acquisition of knowledge regarding child psychology 81 84 88 Feeling more secure regarding their attitudes towards their children and 90 92 71 learning new ways of solving their problems Working through their feelings and worries 90 92 83
Regarding interventions in kindergarten the Prevention Centre of the Municipality of Alimos implemented in 1999 a health promotion seminar addressed to infant school teachers. The seminar aimed at informing and sensitizing teachers in primary prevention issues and at supporting them to implement health promotion programmes at their nursery schools. Although evaluation did not include quantitative indicators, qualitative evaluation data showed that the seminar provided the participants with the opportunity to consolidate previous knowledge and experience and to organize their future interventions within a specific framework.
9.1.2 School Programmes
Although both drug-specific and drug non-specific prevention programmes are still not mandatory at school, interventions in the student population are the first priority of prevention policy nationwide. Within this framework, in 1999-2000 special emphasis was given on the enactment of a holistic prevention approach embracing all different school levels. Thus, albeit interventions at the secondary
83 education level predominate over the others, prevention programmes in primary-school children are continuously expanding, whereas new interventions addressing University students are organized.
School prevention programmes at the primary and secondary education levels involve teachers, parents and the community as agents of change. In this context, prevention centres organize experiential seminars for teachers, school or groups of parents and information-sensitization seminars for the local community agents (i.e. local authorities, the Church, police officers, lawyers, pharmacists, doctors, etc.). Moreover, most of them organize youth programmes outside schools in parallel with the school programmes and they provide secondary prevention services to students who have drug problems and to their families through referrals to therapeutic units.
The objectives of the prevention programmes at the primary and secondary education are conceived according to their three main target-groups: students, teachers and parents (Table 14 ). In order for the delineated objectives to be achieved, the most common approaches used are the active and experiential education through the systemic and community models as well as the psychosocial, the cognitive and the health education approaches.
Table 14: Objectives of the school prevention programmes according to their target-groups
Target-groups Objectives · To develop personal and social skills (i.e. problem-solving ability, resistance to peer-pressure, responsibility, alternative ways of communication) Students · To enhance self-esteem, decisiveness and autonomy · To promote co-operation and solidarity and to improve interpersonal relationships within the classroom · To promote healthy life attitudes and creative activities · To develop active communication and positive atmosphere within the classroom Teachers · To improve their pedagogic relation with their students (i.e. application of active learning methods) · To establish close co-operation with parents and the local community · To be involved in the organisation of preventive activities in their schools · To develop communicative and interpersonal skills within their families Parents · To support them in the parental role · To establish close co-operation with teachers · To be involved in the organisation of preventive activities within the schools
84 According to the information presented in Table 14, school prevention programmes focus on life and social skills development of the general student population rather than on high risk groups. However, prevention centres implement specific interventions in students of high risk on request by their teachers and when it is considered to be necessary they refer them to specialized counselling and/or treatment services. Within this framework, sixteen youth counselling centres have been established in proximity to schools, whereas further ones are envisaged in the near future.
Apart from the local prevention centres, the Ministry of Education also plays an important role in promoting primary prevention in secondary schools, through the organisation of health promotion programmes nationwide. In particular, 1.360 programmes were implemented during the academic years 1997-1998 and 1998-1999, whereas in 1999-2000 the number of the respective programmes was 740, from which 14.5% regarded drug prevention issues. Moreover, the prevention from drug use was the subject of 21% of 52 pilot health promotion programmes implemented in 2000.
Since December 1999, the OKANA participates actively in the implementation of the European project entitled “Away from Home – Drug Prevention Among University Students”. This project, which will last up to June 2001, aims at reducing drug demand as well as the risks from drug use among University students. The particular objectives are as follows:
· To organise counselling, information and referral services within the pre- existing settings of psychological support provided to University students
· To provide specialised training in drug prevention and treatment issues to the health professionals working in these settings
· To create and publish information material regarding drug prevention, which would be adjusted to the particular needs of University students.
The specific guidelines for the implementation and evaluation of this project are under development. Nevertheless, evaluation of school prevention interventions and health promotion programmes at the primary and secondary education has already been advanced, which is evidenced by the fact that an increasing number of prevention centres conduct internal evaluation of their projects every year.
The evaluation results of the pilot health promotion programme entitled “Prevention of drugs, promotion of interpersonal relations and combating academic stress” confirmed that its objectives were achieved to a high degree. The programme was implemented in the academic year 1998-1999 by the “PROTASI” prevention agency in co-operation with the Prevention Centre of the Prefecture of Ahaia. It addressed 194 students of secondary education as
85 well as their teachers and parents. According to the students’ replies in the evaluation questionnaire, 65% of them mentioned that the atmosphere of the class was ameliorated, due to the fact that co-operation and trust among classmates were enhanced. In addition, students reported that many attitudes and behaviours of theirs as well as knowledge about certain aspects changed from “moderately” to “very much” as a result of the particular programme (Table 15).
Table 15: Students’ replies regarding changes in attitudes and knowledge following the programme “Prevention of drugs, promotion of interpersonal relations and combating academic stress”
Aspects of behaviour and knowledge % Controlling academic stress 83.4 Resistance to peer-pressure regarding drug use 76.7 Coping effectively with difficult situations at school 75.1 Coping effectively with difficult situations at home 68.9 Increase of knowledge about drugs 68.9 Increase of self-knowledge 68.4
9.1.3 Youth programmes outside schools
Following the establishment of a close co-operation between prevention centres and actors of the local communities (i.e. schools, parents’ associations, local agencies and media), youth programmes outside schools were further developed in 1999-2000. In most cases, these are organized in collaboration with local cultural associations and athletic clubs, and complement school programmes at primary and secondary school children. Within this framework, they are based on the principal rationale of the prevention school programmes, which is to promote health attitudes as well as to develop personal and social skills.
Youth programmes outside schools consist mainly of leisure activities, cultural events and creative communication groups addressed mainly to adolescents, but to pre-school and primary school children, as well. Special emphasis is also given on approaching boy scouts, girl scouts and group leaders in holiday camps, as well as high-risk young people, e.g. unemployed and school dropouts. The main approaches used are the group-centered model, active and experiential learning and peer education.
The Information-Prevention & Sensitization Center Against Psychoactive Substances «KEPEPSO» of the Prefecture of Messinia organized in 2000 a mixture of various youth programmes outside school, aiming at promoting co- operation among young people and at enhancing their creativity and their personal skills, in general. The programmes that appear to be of high interest are the following:
86 · “Feelings and colours”: Experiential workshop addressed young people aged 14-16 years old, which aimed at training them in expressing their feelings. · Co-operation among adolescents aged 16-17 years old in order to produce a film on adolescence. · Toys’ construction competition among primary and secondary school children. Children produced toys during their teaching hours with their teachers’ and parents’ help.
A preventive intervention entitled «Imagination, knowledge and desire to live being our compass» has been implemented since May 1998 by the Drug Dependence Prevention & Health Promotion Centre «PYXIDA» (Thessaloniki). The programme addresses young people aged 15-24 years old and it is based on social learning model and on peer-education. Quantitative and qualitative evaluation results in 1999 showed that the objectives were achieved considerably. The total number of participants stated that the programme assisted them in developing their social skills and specifically in communicating with others, in trusting themselves more, in expressing their feelings and finally in understanding the role and the influence of their peers. Moreover, they learned to plan, organise and implement preventive and health promotion activities aiming at their peers.
In the context of the particular programme, a meeting between secondary school children and the local youth intervention group for drug prevention and health promotion was organized in 2000. The aim of this meeting was for young people to express their opinions regarding unemployment, education, prevention of drugs and AIDS, environment, free time and entertainment. Their opinions and suggestions were submitted to local authorities, to social, cultural and athletic agencies as well as to school directors, in order for them to take it into account in planning and organizing future interventions.
9.1.4 Community programmes
The underlying philosophy of the Greek community prevention programmes is the following: “Prevention planners increasingly, conduct programmes attuned to the context within which they operate, by taking into consideration that drug related problems call for strategies involving all sectors of society and all the channels running through it” (Malliori et al. 1999, p.90). Hence, prevention is integrated into a wider programme of community interventions and includes joint activities for primary and secondary school students, university students, teachers, parents, mental health professionals, doctors, pharmacists, police officers, lawyers, journalists, the Church, local associations and the local authorities.
The Prevention Centres inaugurated by OKANA and co-financed by local authorities implement community programmes depending on the local needs. Despite their independent action, prevention experts are systematically
87 supported by OKANA in terms of training, supervision during planning and implementation, and evaluation. Training is provided by various institutions and centres, e.g. the “Educational Centre for the Promotion of Health and the Prevention of Drug Abuse” (UMHRI), the “Anthropos Athenian Institute” (AKMA), the “Human Relations Research Laboratory” (EDAS), the “Centre of Therapy for Dependent Individuals” (KETHEA), the “Hellenic Centre for Intercultural Psychiatry and Treatment“ and the “Drug Dependency Unit 18 ANO” (Psychiatric Hospital of Attica) (see also Chapter 10.4 Training for Professionals).
The Drug Dependence Prevention & Health Promotion Centre «PYXIDA» (Thessaloniki) implements a community programme entitled «Collective action in prevention» since May 1998. Up to now, 2.800 persons have participated in it. Based on the qualitative evaluation conducted after a two-year implementation of the programme, the latter appears to have assisted participants in communicating, co-operating and understanding better the role that can play in prevention at their local community. As a result, the following developments were reported:
· A prevention group of volunteers called “THEMELIO” was created in order to inform and sensitize the Parents’ Associations of primary and secondary school children in prevention issues. This group co-operates closely with the Prevention Centre in order for parents’ programmes to be implemented depending on the needs and demands that parents have previously expressed to the group. · Organizations and agencies that deal with young people of high risk formed a network of communication and of cooperation, with the aim to approach their target-group more effectively. · Information and sensitization interventions by the participant agencies became more systematic and they are implemented under the supervision of the Prevention Centre “PYXIDA”.
An innovative intervention at the local community level is the one undertaken since 1998 by the Prevention Centre of the Prefecture of Karditsa. Aiming at integrating in the wider community the various prevention programmes implemented each year and at sensitizing the lay public to participate in future actions, the Prevention Centre organizes a “Local Prevention Week” on an annual basis. Information kiosks, distribution of leaflets and of posters, cultural happenings, seminars and meetings are some of the initiatives included in this local prevention week. Evaluation has shown that this intervention has considerable impact on the local community, since an increasing positive attitude towards primary prevention as well as towards the programmes implemented by the Prevention Centre has been reported.
Although the quantitative assessment of the community programmes’ outcomes is still limited, an indicator of their effectiveness may be the widespread creation of groups of volunteers as well as their increased involvement in preventive activities at the local communities, nationwide.
88 9.1.5 Telephone help lines
While telephone help lines in Greece operated initially only at the national level, there has been an increasing interest since 1998 in expanding their use at the regional and local level, as well. This development emanates from the proliferation of municipal prevention centres nationwide and the need of the population at the local communities to have valid and immediate information on drug prevention and on specialized agencies of prevention and therapy. At the moment, six help lines operate at regional level by prevention centres or other local agencies, whereas three more cover the needs of drug users and their relatives nationwide. All of them are funded by the state and/or by local authorities.
Except for the “Open Line” of the Drug Dependence Unit “18 ANO” (Psychiatric Hospital of Attica), which was the first national telephone help line in Greece established in 1992, two additional national help lines started to fully operate in 2000. The first one is the “SOS Line” of the OKANA, which currently offers referrals and information about treatment options. In order for its services to be expanded, specialized training for the professionals working in the line is now pursued. The second is the “SOS Line” of the “ITHAKI Therapeutic Programme” of KETHEA, which was initially developed in 1998 as a pilot programme under the URBAN initiative. It provides information, counselling and support to the relatives of drug users. The national help line of England, the ADFAM, trained the personnel and it has also undertaken the supervision of the particular line. Following this collaboration between the two services, the adaptation in Greek and the publication of the ADFAM’s educational material is foreseen in the near future (KETHEA 2000).
At the regional and the local level, two new help lines were established in 2000: a. The “Solidarity Line 1037” developed by The Ministry of Macedonia-Thrace, and b. The “Telephone help line of Aetoloakarnania” developed by the “Odysseus” Prevention Centre Against Drugs of the Municipality of Aitoloakarnania.
The “Solidarity Line 1037” aims at providing social care services and psychological support to individuals, families and groups being of high risk or who are socially excluded and they have to deal with hazardous situations. In particular, through the coordinated collaboration with the entire network of the social and health services in Thessaloniki, the line attempts to offer immediate and adequate help to people with special needs, elders, abused women, former prisoners, HIV infected people, refugees and immigrants, homeless people, drug addicts and alcoholics. The average number of phone calls per day is ten, while according to the first evaluation data 1.3% of them regard drug or alcohol dependence issues. The staff consists of six psychologists and a sociologist. Although, the respective line currently covers the local needs of Thessaloniki, its expansion at the geographical regions of Macedonia and of Thrace is envisaged in the near future.
89 The objectives of the telephone help line of the Prefecture of Aetoloacarnania include: a. information about drugs and their risks, b. reinforcement of the users’ and their families’ demand for treatment, c. information about the therapeutic options and referrals, d. parents’ sensitization and anxiety reduction, and e. psychological support. The “Open Line” of the Drug Dependence Unit “18 ANO”, which is provided with systematic training by the FESAT, trained the personnel of the Aetoloacarmania’s line and supervises the programme.
Regarding evaluation of the drug-related help lines, results of the “Open Line” of the Drug Dependence Unit “18 ANO” are consistent with those reported in 1998 (see 1998 Annual Report), whereas evaluation of the newly established lines is still under development.
9.1.6 Mass media campaigns
The issue of drugs has been a main topic of Mass Media in 1999-2000. Various TV and radio broadcasts as well as press articles were dedicated to the different dimensions of the drugs phenomenon in Greece, to the available preventive and therapeutic options dealing with the problem and to the foreseen policy plans of future action. Within this framework, collaboration between Mass Media and therapeutic and prevention centres as well as policy-makers was significantly strengthened.
The press gave special emphasis on the coverage of new demand reduction initiatives, and especially the local press systematically reported demand reduction developments and activities implemented at local level. Moreover, the publication of reports on drugs (i.e. Greek F.P.’s and EMCDDA’s Annual Reports) gave rise to TV and radio debates on particular issues, such as the role of substitution treatment at the national and the European level. Great attention continues to be paid on the coverage of various activities organized on the occasion of the International Day Against Drugs.
A TV programme of high importance was the one entitled “Our own man”, which started to be presented on a weekly basis by a state TV channel at the end of 1999. This programme dealt with significant social issues, such as drugs, AIDS and social rehabilitation. A show of an imaginary personal story concerning the respective issue of each episode occasioned discussions at the panel between professionals, policy makers and persons who faced the problem presented (i.e. drug addicts, their parents, etc.). Moreover, a telephone line was available for other people to participate as well, and to introduce questions and new information. The subject of the first programme was the drug addict’s family, while the second one covered the issue of drug distribution and use in Greek prisons. Representatives from therapeutic agencies, from ministries and governmental bodies participated in the programme.
Within the co-operation framework between demand reduction agencies and Mass Media, the newspaper “Exousia” and the radio station “Planet 104.5” co- funded a concert entitled “Music of the World”, which was organized by the
90 KETHEA’s Therapeutic Community “PAREMVASI” in 2000. Through the organization of this concert, the message that art may contribute to the prevention of drug use was conveyed to the lay public. Moreover, the “9.84” radio station of the Municipality of Athens organized in 2000 a series of broadcasts, with the aim to inform drug users and the wider community on the prevention and health promotion interventions implemented by the prevention centres of Athens. The radio station occupies two former drug users, who completed treatment in drug-free therapeutic communities.
In 1999, two documentary films entitled “Drugs in Europe” and “AIDS in the World – After the storm”, were offered on their demand to TV channels of eight Balkan countries (i.e. Romania, Albania, Moldavia, Bulgaria, Fyrom, Serbia and Croatia). These films, which were directed by a Greek journalist, were initially presented in a state Greek TV channel. The eleven-episode film on drugs that was based on a social research, aimed at increasing public awareness on drugs and of social exclusion in Europe by analyzing different parameters (i.e. production, distribution, types of substances, drug user’s profile, effects from chronic use, prevention, therapy and rehabilitation). The scientific advisor of the respective research was the World Union of Mental Health. Other international companies and organizations, also, asked to be provided with the particular films (i.e. Teleproductions International LTD Virginia USA).
Although information provision to journalists in drug prevention issues has not been systematic, it is continuously increasing mainly by local prevention centres. In this context, and on the occasion of the International Day Against Drugs, the voluntary prevention agency “PROTASI” organised in collaboration with the local press a meeting entitled “Prevention and Mass Media”. The main objective of this meeting was to reinforce the role of Mass Media in primary prevention. In addition, the Prevention Centre “PYXIDA” of the Municipality of Thessaloniki organized in 2000 an educational seminar in co-operation with the TACADE. The seminar considered the influence of Mass Media on the shaping of role models for youth and on the development of critical thinking as a means of primary prevention.
9.1.7 Internet
The use of the Internet as a means of informing the public on drug issues and of promoting drug prevention has not been developed yet in Greece, with the only exception of the website www.medinet.gr. This website, created in 1999 by the non-governmental organization “Social Solidarity”, provides the lay public with first aid and drug-related information. Several reasons may be attributed to the limited use of the Internet for prevention purposes ranging from the preference of a personalized approach in prevention work to the lack of adequate technical infrastructure at the prevention centres.
Nevertheless, special emphasis has been given in 1999-2000 on ensuring the financial and technical means, so as to promote dissemination of prevention know-how among professionals. Two years ago only a limited number of prevention centres had access in the Internet, whereas now half of the overall
91 number of them has solved this problem. The OKANA envisages for the near future not only to supply all prevention centres with the appropriate electronic equipment, but also to provide them with an electronic chat group, through which prevention agents will communicate among themselves and with experts from the OKANA.
Moreover, apart from its own website (www.hol.gr/umhri) that is available to the public since 1997 and which presents updated data on the drug situation in Greece, the Greek Focal Point developed three new electronic databases in 2000. These will provide information on the annotated bibliography that covers the drug-related scientific literature by Greek authors, on the drug-related research in Greece and finally, on the early warning system. Professionals and scientists of the drug field will be able to have access in them by the beginning of 2001. Two additional databases in the demand reduction field are also being prepared by the Foal Point. The first one, will be based on the “Inventory of the Drug-specific Prevention and Therapeutic Services” (Boukouvala et al. 2000) and it will consist of the structural and functional data on the prevention and therapeutic agencies that operate nationwide. The second will offer detailed information on the current prevention and treatment programmes according to the EDDRA questionnaire and it will also provide professionals with the opportunity to exchange experience through electronic chat groups.
The use of the Internet is also limited in the therapeutic field. The KETHEA is the only therapeutic agency that offers detailed information on its different programmes implemented nationwide, through a website (www.kethea.gr).
9.2 Reduction of drug related harm
9.2.1 Outreach work
More emphasis started to be given on outreach work during 1999-2000. Thus, except for the continuation of the three existing outreach programmes (i.e. the KETHEA “Pegassus” Mobile Unit, the Streetwork programme of the KETHEA Multiple Intervention Centre and the Streetwork Programme of OKANA’s Help Centre), other therapeutic centres initiated outreach initiatives at local and regional level.
The interventions of “Pegassus” are carried out on invitation by the local authorities and other local agents with a view to make the local community aware of the problems associated with the use of drugs and also to motivate drug users to seek treatment. Thus, the strategies applied are mainly the community/family approach, the public health model and the youth work approach. In 1999, “Pegassus” visited twelve cities throughout Greece. Moreover, in 1999 “Pegassus” implemented primary prevention programmes at several workplaces and programmes outside school for young people aged 15- 20 years old. The latter aimed at demystifying drug use and at promoting quality of free time and entertainment through the organization of alternative activities and happenings.
92 The streetwork programmes of KETHEA and OKANA take place at drug scenes in the Athens area. Using the “catching client” and the “public health” models, the Streetwork Programme of the KETHEA Multiple Intervention Centre came in contact in 1999 with 1,524 users being homeless, prostitutes or ethnic minorities. The primary objective of the programme is to establish contact and communication with drug users so as for them to be motivated in making either minor or major changes in their life.
Based on a harm reduction approach for drug users not receiving treatment, the Streetwork Programme of the OKANA Help Centre, in 1999 approached 2,218 drug users. The programme aims at informing drug users about harm reduction from infectious diseases, and at motivating them to adapt healthy attitudes as well as to seek treatment. Thus, counselling and information on safe drug use, distribution of clean syringes and referrals to the medical and social services of the Help Centre are included in its activities.
The Mobile First Aid Unit is another service provided by the OKANA Help Centre, which offers ambulance services in cases of emergency (i.e. overdoses) and transfers drug users to general hospitals in Athens. In 1999, the Unit provided its services to 1,401 drug users.
Although outcome studies are not systematic due to the nature of the work, it has been reported that a considerable number of drug users seek treatment as a result from streetwork interventions.
On these grounds, streetwork initiatives were expanded in 1999. The Counselling Centres of KETHEA have systematized their streetwork interventions with the aim to inform drug users about infectious diseases and other risks from drug abuse and to motivate them for treatment. For example, the therapeutic programme “EXODOS” organized in co-operation with the Mobile Unit “Pegassus” and the local Prevention Centres a ten-day information and sensitization campaign addressed to drug users in central Greece. Drug users who are under treatment at the therapeutic community «NOSTOS» also undertook a seven-day information campaign. Apart from this campaign, which took place at the islands of Argosaronikos, the counselling centre of “NOSTOS” implements streetwork programmes in Piraeus on a regular basis. Outreach work is foreseen to be expanded in Thessaloniki as well, with the inauguration of a low threshold service there by OKANA.
9.2.2 Low threshold services
OKANA and KETHEA currently provide low threshold services. Both of them address their services to drug addicts who do not wish to enter treatment and who additionally appear to encounter serious health and social problems.
The Multiple Intervention Centre of KETHEA offers to drug users counselling services, psychological support, self-help groups, creative and recreational activities, nutrition, clothing and referrals to public hospitals (for more information, see 1998 Annual Report). Moreover, drug users are provided with
93 dental services within the premises of the Centre. A development in the provision of low threshold services was a drop-in centre established in 1999 at the premises of the Multiple Intervention Centre. This centre entitled “Off Club”, aims at promoting harm reduction from drugs and at motivating drug users for therapy. It provides hygiene services, nutrition and creative activities. An innovation of the Club is a touch screen programme through which drug users can find information about the services of the KETHEA. In 1999, 1,398 drug users visited the “Off Club”.
Harm reduction at health, psychological and social level is the primary objective of the OKANA Help Centre, as well. In order to achieve this objective, the Help Centre has developed an well-organized network of services. This includes various programmes, the interventions and clients of which in 1999 are presented below in details:
· A general health clinic of primary care, which also provides systematic information on safe drug use. The overall number of clients in 1999 was 1,747 drug users. · A fully equipped microbiological laboratory established in 1999. · A dental clinic, with 728 clients in 1999. · A social service, which provides information on and referrals to therapeutic programmes and to other social services for housing, employment and financial issues. Also, it offers psychological support and it organizes seminars on safe drug use, prevention of infectious diseases and hygiene issues. 302 drug users visited the social service of Help Centre in 1999. · A legal service, which provides legal advice to drug users as well as legal support to members of the Substitution Programmes, in cooperation with the Lawyers’ Association. 201 drug users were provided with legal services in 1999. · A telephone help line, which started to fully operate in 2000. · A streetwork programme and a mobile first aid unit (see Chapter 9.1.1. Outreach Work) · A syringe exchange programme, which is implemented within the Help Centre. In 1999, 86,819 overall syringes were exchanged. · An early intervention programme for delinquent adolescents (see Chapter 9.6. Interventions in the criminal justice system).
Health and legal services of the Help Centre are available not only for the drug users who visit the Centre, but also for the clients of the OKANA Substitution Programmes as well as for drug users who are referred by other specialized therapeutic centres.
Evaluation results in 1999 show the positive overall outcome of the Help Centre work. In particular, the numbers of new and former clients have been increased compared to the figures of last year. 1,136 new clients visited the Centre in 1999, whereas the number of new clients in 1998 was 635 drug users. Also, while the clients approaching the Centre for a second or third time was 662 in 1998, this figure was considerably increased in 1999 (1,842 clients). An increase was also reported in exchanged syringes (86,819 syringes in 1999 compared to 46,660 in 1998) and in the number of drug users who recovered
94 from overdose after the prompt intervention of the Mobile First Aid Unit (1,401 in 1999 compared to 1,055 in 1998).
On the grounds of these positive results and in order to cover the lack of low threshold services in the city of Thessaloniki, OKANA envisages the establishment of a Help Centre there in the near future.
9.2.3 Prevention of infectious diseases
See Chapter 14.3: New developments and uptake of prevention, harm reduction and care
9.3 Treatment
9.3.1 Treatments and health care at National level
The existing treatment unit types in Greece are: Drug-free residential therapeutic communities (8), non-residential therapeutic centres (9 for adults and 4 for adolescents), methadone substitution (4) and methadone maintenance units (1), and low-threshold programmes (2) (Figure 30).
Figure 30: Types of therapeutic programmes in 2000
N
14 13
12
10 8 8
6 5
4 2 2
0 Residential/drug-free Non-residential/drug-free Methadone substitution Low-threshold and maintenace
SOURCE: Therapeutic programmes’ network of the Greek Focal Point, 2000
The main objectives of all types of treatment units include total abstinence from illegal drugs, improvement of personal and social skills, of health and of family and social relations, decrease of deviant behaviour and occupational integration. In particular, 70% of the treatment programmes refer total abstinence from illegal drugs to be their main objective, while the development of self-esteem and of self-knowledge is the main objective of 20% of the therapeutic programmes. The well being and the improvement of physical
95 health and of daily life skills are considered as primary goals by the 10% of the treatment units.
Along with the treatment, therapeutic programmes also provide other special services in order to meet the multiple needs of drug users more effectively. In this context, more than half of the therapeutic units provide psychiatric help (60%) and supportive interventions that assist individuals to get a regular occupation (55%), while half of them offer vocational guidance. Other special services which are provided in the context of the main therapeutic procedure are the following: after-care services (45%), housing assistance (30%), basic medical help (25%), basic/academic education (15%), financial help (10%), vocational training and scholarships (10%).
Moreover, half of the therapeutic units report that they provide services tailored to special groups of drug addicts (i.e., drug users facing psychiatric problems, adolescents, users under probation, pregnant drug users, etc.). In 1999, adolescent drug users corresponded to the 12.9% of the total number of drug addicts under treatment.
Regarding most treatment units’ staffing, a total number of 315 professionals provided specialised services to drug addicts in 1999. Therapeutic programmes’ staff consists mostly of mental health professionals (52.3%). Medical staff (i.e. doctors, nurses) corresponds to the 15.6% of the total number of personnel (Table 16).
Table 16: Staffing of the therapeutic programmes in 1999
RESIDENTIAL NON NON METHADONE TOTAL PROGRAMMES RESIDENTIAL RESIDENTIAL SUBSTITUTION ( =8) PROGRAMMES PROGRAMMES PROGRAMMES FOR ADULTS FOR ( =4) ( =6) ADOLESCENTS % ( =3) Psychiatrists 5 7 - 12 24 7.6 Other doctors - - - 3 3 1.0 Psychologists 9 9 11 15 44 14.0 Social workers 5 6 3 17 31 9.8 Consultants 5 3 - - 8 2.5 Other therapists or Trainers 28 17 21 - 66 20.9 Nurses 22 2 - 22 46 14.6 Other specialized personnel 2 3 1 4 10 3.2 Administrative personnel 4 11 3 33 51 16.2 Others1 3 20 4 5 32 10.2 83 78 43 111 315 100.0 TOTAL % 26.3 24.8 13.6 35.2 100.0
1 Sociologists, art therapists, physical education teachers, education personnel.
96 All agencies that run Therapeutic Programmes lay emphasis on the continuous education of the staff, the promotion of communication at all levels and the provision of incentives. Training activities aim to promote scientific knowledge and know-how, to prevent the burn-out syndrome, to help staff members develop their skills in order to be able to adjust to the ever-changing needs of their work and, least but not last, to improve the services provided to addicted persons and to their families. For example, KETHEA’s training programmes concern themes, such as drug counselling, counselling to addicted mothers, relapse prevention, health management, family therapy, and street-work interventions.
Regarding the funding sources of treatment units, most of the therapeutic programmes’ expenditures were covered in 1999 by Governmental agencies (57.7%), while funding from European Union and donations covered in most of the cases less than 50% of the programmes’ expenses (Table 17).
Table 17: Funding sources of the therapeutic programmes
Percentage of expenditure covering TOTAL Funding Sources 100% 99%-70% 69%-40% 39%-10% % Governmental agencies 9 4 2 ¾ 15 57.7 European Union ¾ ¾ 1 3 4 15.4 Donations 1 ¾ ¾ 6 7 26.9 TOTAL 8 5 4 9 26 100.0
According to the data from the First Treatment Demand Indicator and the KETHEA’s records, the degree of involvement of public health services and GPs in the process of referrals to drug services in 1999 was as follows: 7,3% of the total patient population is referred by Hospitals and other medical units, 3,6% was referred by GPs and 2,6% was referred by social services. Due to the fact that data from KETHEA are provided to the Focal Point in an aggregated form, it is necessary to point out that the statistic double counting error comes up to 5%.
The main characteristics of the drug-free residential and non-residential treatment units as well as their therapeutic goals are presented below.
Drug-free Residential Treatment
Eight out of the twenty-eight treatment units in Greece are residential. Situated in different parts of the country provide a large range of services to adults drug users. The treatment lasts approximately from 12 to 15 months and is provided on a voluntary basis. Applying individual and group therapy through a systemic, cognitive or psychodynamic approach succeeds the objectives of these
97 programmes, which are abstinence from drug use and emotional maturation. Emphasis is also laid on the continuous educational and vocational training, which contribute to individuals’ rehabilitation. The main characteristics of the therapeutic programmes belonging in this category are presented below.
“ITHAKI”, the first therapeutic community in Greece established in 1983, is situated at the outskirts of Thessaloniki. Similar to all the other KETHEA therapeutic communities, “ITHAKI” follows the Therapeutic Community Self- Help Model Approach. It runs a rich educational programme for its members, with classes in literature, judo, pottery, theatre, drawing, music, etc. In 1999, the number of clients at the therapeutic community was 156 persons and new admissions reached the number of 56 individuals.
The counselling units of the Therapeutic Community “EXODOS” are situated in Larissa and Volos, two major cities of Central Greece and they have been covering the needs of the broader geographical area of this part of the country for the last 10 years. Since 1999, “EXODOS” has been providing services to the parents of adolescent users, although the programme is addressed to adults. “EXODOS” is currently planning the establishment of a comprehensive treatment programme for adolescents that will cover the increasing needs of this part of Greece.
The Therapeutic Programme “PAREMVASSI” is located in Attica and has been offering services to drug addicts for the last 10 years. Along with the therapeutic services, the programme is also active in protecting the environment and in running other social or ecological intervention projects. For example, in 1999, PAREMVASSI’s interventions included a reforestation project in Attica.
Located in Piraeus, “NOSTOS” not only offers treatment services to adult drug users and to their families, but also it contributes to the preservation of the Greek nautical tradition by forming a group that aims to maintain the traditional craftsmanship of shipbuilding. In 1999, NOSTOS’ groups of silversmithing and creative writing exhibited and presented their work in Athens and Piraeus.
The network of inpatient services of “18 ANO” consists of a Residential Treatment Programme and a programme tailored to the special needs of women (Residential Women’s Treatment Programme). Therapy is approached in a pluralistic way combining psychodynamic, cognitive and systemic methods. The residential therapeutic programmes of “18 ANO” provide basic medical care, psychiatric care, individual counselling, group and individual therapy, self-help groups, family therapy, after-care services and vocational assistance.
The Therapeutic Community of Karteres belongs to the Drug Dependence Treatment Unit of the Psychiatric Hospital of Thessaloniki and provides group and individual therapy based on the Milieu Therapy approach.
A residential drug-free programme directed by the First Evangelical Church of Athens, named “Philimon”, offers help to drug addicts basically in accordance
98 with supportive group therapy and Christian principles. In 1999, provided its services to 28 drug users.
Drug-free Non-residential Treatment
There are thirteen non-residential treatment programmes: four non-residential therapeutic communities (two for adults and two for adolescents), one day-clinic and eight outpatient centres. Motivation and preparation for treatment, counselling, detoxification, family therapy and rehabilitation are the main types of treatment services offered by almost all these non-residential units. The main characteristics of the non-residential programmes are presented below.
The outpatient treatment units of KETHEA are abstinence-oriented programmes, applying a psychosocial approach based on the therapeutic self- help community model in conjunction with the systemic model. Group and individual therapy services are provided to drug users and members of their social system (parents, brothers/sisters, other relatives, etc.).
“STROFI” is the only therapeutic programme of KETHEA that is addressed to adolescent drug users and their families. The offered services are the following: The Therapeutic Programme for Adolescent Drug Users and their Families, the Secondary Prevention Centre for high-risk young people and the Counselling Centre in the Public Prosecutors Office in Athens (see also Chapter 9.5. Interventions in the Criminal Justice System). All programmes offer family therapy aiming at the reconstruction of the family system. Also, a halfway house is at the disposal of adolescents from areas outside Athens.
STROFI’s Secondary Prevention Centre is addressed to adolescents (aged 13- 21) who use drugs on an experimental basis, who have educational and/or professional activities, and a family background capable of providing support for abstinence from drugs. The Centre consists of four main units: The Secondary Prevention Counselling Unit, the Secondary Prevention Community, the After- care Unit (Follow-up) and the Unit of Family Therapy and Counselling. The programme aims at preventing further adolescents’ involvement in drugs. It provides adolescents and their families with individual, group and family therapy services, as well as recreational, cultural, athletic and artistic activities. Staff includes ex-dependent individuals. In 1999, the Secondary Prevention Centre provided services to 112 adolescents and 287 adolescents’ parents/other relatives.
STROFI has established a transitional school for its members who usually drop out of school at an early age. The curriculum includes, among others, vocational training and computer literacy. Specialized teachers of all educational levels and specialized trainers run the classes and special emphasis is given on handling learning difficulties. Special scholarships are given for instructional purposes. Great emphasis is placed on the continuation and completion by users of primary and secondary schooling, supported by peer-education methods and computers. In 1999, 28 pupils participated and
99 succeeded in final exams. In total, during 1999, STROFI’s transitional school provided its services to 62 adolescents.
“DIAVASSI”, a non-residential programme addressed to adult drug users, meets the needs of drug dependent individuals who are able to lead a relatively stable life and who are in fairly good terms with their families that support their abstinence efforts. Treatment is combined with a multitude of sociocultural activities such as those held by the “DIAVASSI Cultural Centre” (exhibitions, films, concerts and theatrical plays) in co-operation with the local community. In 1999, “DIAVASSI” set up a Work Club in order to meet the needs of former drug users who are in search of a job. The Work Club of DIAVASSI carries out a variety of activities, such as counselling in order to help its members with problems related to work and seminars on working issues. The Evening Programme for working addicts of DIAVASSI is addresed to drug addicts who are socially integrated, who have a permanent or a part-time job, who follow training programmes and have family support. The programme aims to help members remain abstinent, improve their ability to work and help them develop their social skills.
“ARIADNI” therapeutic programme covers the area of Crete. It is an open care programme founded in 1999 and consists of a Counselling Centre, a Therapeutic Community (under construction), a Rehabilitation Centre and a Family Therapy Programme. “ARIADNI” is mainly addressed to adult users, but also it provides counselling support to adolescent users and to their parents. In 1999, the therapeutic communities of KETHEA covered their capacity by 86,6% (KETHEA 2000) and they provided their services to 802 persons.
The Department for Adolescents and Young Adults of the Drug Dependence Unit “18 ANO” has a psychological treatment orientation characterized by the highly individualized approach of exploring intrapsychic conflicts. Emphasis is on identity problems of adolescents and young adults. Supportive, psychodynamically oriented psychotherapy is the treatment method used by the programme. Staff does not include ex-dependent individuals.
The Programme of Family Therapy and Counselling (“18 ANO”) is an outpatient treatment service addressed to drug users who have a permanent occupation or attend educational/training programmes and have a rather stable relationship with their family members who support their efforts. Counselling and therapeutic services are also provided to family members and other relatives based on a systemic approach.
The programme for Dually Diagnosed Persons (“18 ANO”) is addressed to drug users facing psychiatric problems. The programme offers several services such as psychiatric care, individual counselling, group therapy, family therapy, legal support and vocational training.
The Therapeutic Programme “ATHENA” (Psychiatric Department of the Athens University Medical School / OKANA) is an outpatient unit which provides individual and family therapy interventions in the context of a systemic approach as well as medical, psychological and social rehabilitation services.
100 The “IASON” Day Centre of Athens Mental Health Centre provides individual psychotherapy, group therapy, early intervention and parent group services. The main treatment approach is an individualised eclectic model composed of psychoanalytic, person-centered and systemic theory elements.
The OKANA Non-residential Therapeutic Programme “GEFYRA” in Patras (West Greece) consists of a multiphase network of services covering psychosocial needs of dependent individuals and of their families. Special emphasis is given on active family involvement in the therapeutic process.
The Alternative Therapeutic Programme “ARGO” of the Psychiatric Hospital of Thessaloniki is an outpatient treatment service addressed to drug users who have a permanent job or follow educational programmes and have family support. Counselling services are also provided to family members.
As it may be obvious from the above data, great emphasis has been placed on the development of long-term stationary, inpatient, high-threshold facilities where admissions are often based upon a waiting list and treatment is abstinence-oriented. The majority of treatment programmes are addressed to adults and the predominant therapeutic approach, which is applied to all therapeutic communities, is the Therapeutic Community Self-Help Model.
9.3.2 Substitution and maintenance programmes
Following the successful pilot phase of the first two substitution units established in Athens (capacity 200) and Thessaloniki (capacity 100) in 1996, OKANA inaugurated two more units in these cities (capacity 200 and 150 accordingly) in 1998. Along with these four methadone substitution programmes, other therapeutic organizations also prescribe narcotic antagonists whenever it is needed (see 1999 Annual Report submitted to the EMCDDA). The Ministry of Health monitors all these therapeutic programmes on a regular basis.
Admission criteria for all Substitution Programmes in Greece are the following: being an IV heroin addict of more than 22 years of age, having at least a two- year drug use and having unsuccessfully tried other treatment. Priority is given to addicts with HIV, cancer or other somatic illnesses, to pregnant women after the third month of their pregnancy, to addicts with psychiatric problems, to people using drugs for a long time, to polydrug users and to first degree relatives of clients.
The clients of the four OKANA Substitution Programmes receive methadone as an integral part of their treatment plan, as well as Naltrexone whenever it is needed. Moreover, the two Substitution Programmes in Athens prescribe antidepressants (i.e. Amitriptyline, Desipramine), benzodiazepines (i.e. Chlordiazepoxide, Diazepam, Alprazolam, Flurazepam), antipsychotics and antimanics (i.e. Tegretol).
101 The main objectives of the substitution treatment programmes are gradual detoxification and harm reduction. Addicts, also, receive psychological support through individual and group psychotherapy, medical support, and assistance for social integration and relapse prevention. Moreover, psychiatric help, family therapy, and social skills groups are also provided. The completion criteria of treatment are total abstinence from all drugs (i.e. negative urine tests for at least I year) including methadone, improvement of physical and mental health, and of social skills, and successful social integration. Up to now, the duration of the therapeutic programme was approximately three years.
Nevertheless, after the four-year implementation of methadone substitution programmes, OKANA decided in 2000 on several modifications and developments regarding substitution treatment in Greece, based on specific research and evaluation data. According to these data, although the objective of harm reduction was achieved by 60%-79% of the patients, only 8.5% to 12% of them had achieved total abstinence from all drugs including methadone, while half of them had become abstinent within the first year of their treatment. Moreover, despite the fact that demands for substitution treatment were continuously increasing, the possibility for new clients to be admitted was limited because of the accumulated number of addicts staying in the Units for longer than two or three years. As a result, more than 4,000 addicts are currently in a waiting list for substitution treatment.
In order to overcome these problems and to subsequently increase effectiveness of substitution treatment, OKANA has already taken the following steps:
· The duration of the substitution therapeutic programme aiming at detoxification was decreased from three years to eighteen months. · The frequency and the quality of the provided psychosocial services were increased, while special emphasis was given on social rehabilitation and relapse prevention programmes. · Methadone substitution programmes were separated from maintenance ones. A maintenance unit was already established in Athens (capacity 100) in 2000, while three more with the same capacity each are foreseen to be inaugurated in the near future (one in Athens, one in Piraeus and one in Thessaloniki).
Moreover, OKANA envisages to have inaugurated until 2003 three new substitution programmes (capacity 60-80) at the regional level and specifically in Larisa, Patras and Crete.
Attention will be also paid in the systematic and continuous training of the substitution-maintenance programmes’ personnel. According to 1999 data, the professionals working at the Substitution Programmes are psychiatrists (12), psychologists (15), medical doctors (3), nurses (22), social workers (17) and administration personnel (33) (Table 16).
102 Evaluation of the programmes takes place on a systematic basis. The first data are collected through a semi-structured interview by a psychiatrist (Pompidou Group’s “Treatment Demand Indicator”). In the course of treatment urine and blood are tested for drugs and infectious diseases. Patients are additionally addressed by EuropASI (European Addiction Severity Index) and OTI (Opiate Treatment Indicator), and personal data files are stored in a data bank for the purpose of statistical analysis. Clinical and laboratory follow-ups take place after a 6-month period.
Specific outcome data in 1999 regarding the existing substitution units remain the same with the ones presented in the last year’s Annual Report (see 1999 Annual Report submitted to the EMCDDA).
9.4 After-care and re-integration
In 1999-2000, policy-makers and treatment agencies continued to lay emphasis on the development of after-care services. Thus, along with the existing ones, new programmes were initiated at this period aimed at drug users who complete treatment, discharged prisoners and long-term substitution clients.
In this context, in 1999 the KETHEA therapeutic programme “DIAVASSI” developed a Work Club aiming at assisting former drug users in their pursuing for a job and at supporting those who work already. In order to achieve these objectives the Work Club carries out several activities, which include the following:
· Collecting and organizing printed and electronic information on occupational issues (i.e., subsidized employment programmes for former drug users). · Individual and group counselling, so as to help former drug users to cope with stress and with difficulties at their work or in finding a job. · Organization of seminars on various working issues (i.e., CV composition, developments in the labour market and relationships at work). · Collaboration and exchange of information and expertise with other agencies that deal with unemployed persons’ support. · Information and sensitization of employers about former drug users in search of a job (KETHEA 2000).
Except of this programme, the Cultural Centre of “DIAVASSI” enriched its creative and educational activities. In 1999, several individual and group art exhibitions, music nights and seminars were organized, while the first issue of a journal entitled “Notebooks of DIAVASSI” was published. The journal was produced by the vocational training group on graphics, as an attempt to inform the lay public about the therapeutic programme. In 1998-1999, this group had the opportunity to attend a subsidized educational programme of 600 hours on electronic printing.
103 Qualitative and quantitative evaluation results from all KETHEA social rehabilitation centres remain positive. In 1999, 293 former drug users participated in these social rehabilitation centres. The average number of persons in treatment was 147, whereas the capacity of the centres is 130 places. Being 113% full, the social rehabilitation centres exceeded their capacity for the fourth consecutive year. Moreover, evaluation results showed that 100% of participants stay abstinent from all illicit drugs and do not exhibit deviant behaviour, 95% have a full-time occupation or continue their education, and all of them ameliorate their family and social relations. The 4/5 of all clients attending the Social Rehabilitation Centres successfully complete treatment. Hostels are provided to former drug users by all KETHEA Social Rehabilitation Centres, until they find a job and they are settled down.
OKANA was also active in 1999-2000 in promoting social rehabilitation and after-care services for former drug users as well as for long-term substitution clients. A Vocational Training Centre, which started to operate in April 2000, will cover the need for social and vocational re-integration of ninety overall former drug users. The European Community funds this programme, which is also co-funded by the Ministry of Labour. Each participant in the vocational training seminars will be subsidized with 5 Euro per hour. Moreover, in September 2000 OKANA developed a social rehabilitation unit (capacity 50) for former drug users who complete methadone substitution treatment in Athens as well as for those who attend the newly established methadone maintenance programme. The programme lasts for a year and provides psychological therapy, vocational guidance and social rehabilitation services. Two more social rehabilitation programmes (one in Athens and one in Thessaloniki) are foreseen to be established in the near future.
The Ministry of Labour continued its initiatives in 2000 to assist the re- integration of socially excluded groups into the job market. In collaboration with the “Employment Organization of Labour Force” (OAED), it developed new programmes addressed to former drug users who have completed therapy and to discharged prisoners. In particular, this initiative includes the following interventions:
· The provision of 490 subsidized vacancies at the private sector (300 for ex- addicts and 190 for discharged prisoners). The subsidy will be 20-23 EURO per working-hour for three years. · The provision of 250 subsidized vacancies of self-employment (120 for ex- addicts and 130 for discharged prisoners). The subsidy will be 15,440 EURO.
The “Supporting Centre for prisoners or discharged prisoners”, which is run by the KETHEA therapeutic programme “ITHAKI” in Thessaloniki, provides further rehabilitation and social reintegration services for discharged prisoners, through psychological support, family therapy, and vocational guidance and training.
104 9.5 Interventions in the Criminal Justice System
Police Prevention Activities
Except of the Educational Centre for the Promotion of Health and the Prevention of Drug Abuse that continued to organize training programmes for police officers on a regular basis, most of the prevention centres nationwide have also expanded their interventions in the local police. The prevention programmes addressed to police officers include sensitization seminars on prevention issues as well as information about the existing therapeutic options.
The Prevention Centre for Combating Substances «ELPIDA» of the Municipality of Thessaloniki implemented in 1999 a respective seminar entitled "Suppression and Prevention: Two sides of the same coin". Evaluation results after the programme’s implementation showed that 87% of the twenty participants comprehended the common aspects and the differences between prevention and suppression, while 90% of them considered that prevention programmes are essential and expressed their will to contribute to prevention. Moreover, all participants stated that the programme assisted them in understanding the psychosocial factors that lead to drug use as well as issues regarding adolescence.
Arrests and referral to drug services
In 1999, 98 adolescents and 150 parents and siblings approached the Counselling Centre for adolescents at the Probation Services Office in Athens. Aside from counselling and treatment services, which have been provided since 1998, the centre has also taken up in 1999 a vocational training programme aiming at preventing adolescents’ social exclusion, at educational rehabilitation and at abstinence from drugs. This vocational programme, which is addressed to twenty adolescents, includes: a. training in PCs and in graphic- artistic programmes, b. classes in modern Greek literature, history and culture, c. seminars concerning the adolescents’ rights and obligations, and d. theatrical games, painting and sports.
The Outreach Pilot Programme for Prevention and Early Intervention in Juvenile Delinquents, which was initiated by OKANA in September 1998, address adolescents aged 13-17 years old, who use drugs on an occasional basis and have previous arrests for drug possession and/or use. Adolescents and their families are referred to the programme by the Juvenile Commissary Service, which constitutes the exclusive source of its referrals. In 1999, the programme provided its counselling and psychotherapy services to 38 families. The main objectives are to develop adolescents’ personal and social skills, to assist them in their social integration, to support parents in their parental role and to promote social networks of solidarity.
105 Imprisoned population
Interventions aimed at drug users within prisons are currently limited to the systematic organization of self-help groups, which are run on a voluntary basis by the KETHEA, the Drug Dependence Unit “18 ANO” and the Narcotics Anonymous. These programmes aim at harm reduction of infectious diseases, information on the therapeutic programmes, motivation to therapy, and preparation for enrolment into treatment.
According to the Law 2331/1995, article 21, the successful attendance and completion of the support programmes offered to drug dependent prisoners, give them the opportunity to interrupt their custody in order to enroll into a therapeutic community. The time spent in treatment is considered as equivalent to the time the person would spent for the serving of custody. Also, the successful completion of the therapeutic programme leads to a temporary suspension of the sentence for three to six years.
Four hundrend fifty nine addicted prisoners participated in the KETHEA support programmes in 1999. Moreover, in 1999 the Multiple Intervention Centre in collaboration with the organization “Médecins sans Frontières” carried out seminars concerning health issues, which were addressed to the support programmes’ participants. Further seminars on AIDS and Hepatitis were organized for the Women Prisons’ personnel. The Ministry of Justice organized a congress entitled “Correctional System and Combating of Drug Use” in cooperation with KETHEA. The congress was addressed to all professionals working in correctional institutions. The two main issues of the congress referred to the ways of dealing with drug dependent prisoners and the required support services for discharged prisoners.
Evaluation of support programmes to drug dependent prisoners is currently conducted on the basis of the following indicators: number of participants in the self-help groups, consistency of participation, and referrals to therapeutic programmes. Results regarding the intervention organized by the Therapeutic Programme “EXODUS” in the Kassaveteia’s Prison showed that prisoners as well as the prison’s management highly valued the importance of the programme. This resulted to an increase in the number of participants from 6-8 drug users to 20 persons after the first sessions.
At the end of 1999, KETHEA also established a Support Centre for Prisoners and Discharged Prisoners run by the therapeutic programme “ITHAKI” in Thessaloniki. The Centre has two supporting structures, both inside and outside the prison setting, aiming at harm reduction, enhanced motivation to treatment, vocational guidance, and rehabilitation and social integration.
The Drug Dependency Unit “18 ANO” has developed since 1995 self-help groups for drug dependent prisoners belonging to ethnic minorities.
No syringe exchange programmes, drug testing interventions or treatment services (drug-free and substitution ones) are provided within Greek prisons at
106 the moment. However, the Detoxification Unit for Drug-Dependent Prisoners, which will start to operate in the near future under the auspices of the Ministry of Justice, will attempt to cover the lack of treatment options within the prison system. In this context, a coordinating committee was formed in 2000, aiming at deciding on the principles of the Unit’s operation, on the selection-criteria of the prisoners who will attend the programme, and on the personnel’s training.
The main objectives of the Unit are physical detoxification, psychological recovery and social rehabilitation. The Unit will recruit approximately 300 out of the 3,000 drug addicted prisoners. Drug dependent prisoners who are eligible for being admitted in this treatment programme should have served 1/5 of their sentence and they should be accused for misdemeanors and not of felonies. Treatment will take place on a voluntary basis. Three types of detoxification programmes will be available in the Unit:
· a drug-free programme addressed to drug dependent prisoners of more than 21 years old · a substitution methadone programme · a drug-free programme addressed to juvenile and young adults delinquents of 14-21 years old.
The therapeutic programme will consist of several phases that will include: a. preparation and motivation (2-3 months), b. physical detoxification, c. psychological treatment (1 year), and d. social rehabilitation (1 year). The members of the programme should participate in all phases.
According to the findings of the Leonardo Da Vinci research project on the needs of juvenile delinquents for vocational training (Aristeteleion University of Thessaloniki 2000), only 4% of the young people who are in correctional institutions have been offered some kind of support from social services. In this context, the research team stresses the need for psychological support services addressed to adolescents of this group and to their families to be developed. Moreover, they suggest that a nine-year mandatory education based on the different age groups and group-specificities (e.g. adolescents being foreign speakers) should be established, so as juvenile’s social and vocational rehabilitation to be facilitated. Finally, it is required that drug-dependent juvenile delinquents should be referred to specialized programmes.
9.6 Specific targets and settings
9.6.1 Gender specific issues
Two therapeutic agencies have established specialized programmes for women drug addicts: the Drug Dependence Unit “18 ANO” (Psychiatric Hospital of Attica) and the KETHEA. Except of these treatment services, the streetwork programmes in Athens of OKANA and of KETHEA provide special services for drug addicted prostitutes who do not approach therapeutic programmes,
107 through counselling, motivation for therapy, referrals to public hospitals, condoms and information leaflets for harm reduction.
The Treatment Programme for Dependent Women (“18 ANO”), which was established in 1997, it was developed in an attempt to meet the particular needs of this target-group (i.e. sexual abuse, family neglecting, pregnancy, motherhood, etc.). The therapeutic models, objectives and services provided by the programme are the same with the ones of the mixed Therapeutic Programme of the Drug Dependence Unit. Creative activities, such as painting and literature, are also provided.
The total number of participants in the programme in 1999 was 30 persons. Evaluation results showed that women integrate more easily in society after completing treatment compared to men (74% of women vs. 54% of men), while they have a smaller number of relapses (1.7% vs. 7%, accordingly). Women praise the advantages of being in a specialized programme, since they feel freer to express their feelings.
Moreover, in 1999 the KETHEA Therapeutic Community “ITHAKI” in Thessaloniki, under the European initiative URBAN, developed a specialized programme for drug-dependent pregnant women and mothers who want to enroll in treatment. A nursery for their children is provided through this programme, which is the only one for children of drug users in Greece. The programme is co-funded by the Ministry of Macedonia and Thrace.
9.6.2 Children of drug users
The nursery for children of drug dependent mothers established in 1998 by the KETHEA Therapeutic Programme “ITHAKI” is the only programme for children of drug users in Greece. This nursery, which was developed in order to support addicted mothers in the process of therapy and social rehabilitation without having to be separated from their children, provide the latter with creative occupational and care services by specialized personnel. The programme is co- funded by the European Community and the Ministry of Macedonia and Thrace.
The Child’s Health Department of the Aristotelian University of Thessaloniki conducted an innovative study regarding children of drug users from 1997 to 1999 (Georgakas 2000). The main aim of the project was to explore the possible consequences of parents’ substance abuse on their children. The sample consisted of 55 children aged from 6,5 months to 11 years old and their parents. All fathers and 50% of the mothers who participated in the study were addicted to drugs. The main methods of data collection regarding children included the following: a. interviews with parents, b. medical and school records, c. clinical diagnoses, and d. psychometric tools (i.e Eynzech’s Personality Questionnaire for Children, Parents Diagnosis Questionnaire).
The research findings showed that the exposure of children to specific conditions results to several physical or behavioural problems. For example, 18.1% of the children participated in the study suffered from withdrawal
108 syndrome for 48-72 hours after their birth, due to the drugs taken by their mother during pregnancy. 3.6% of them had been infected with Hepatitis C, transmitted by their mothers. Also, most of the children had emotional and behavioural problems because of dysfunctional family relationships. According to the results of the Parents Diagnosis Questionnaire, children aged from 13 months to 10 years old with drug dependent parents appeared to demonstrate high rates of: sensitivity (58.8%), disobedience (47%), need for support and protection (33.3%), jealousy (31.3%), dependence (31.3%), aggression (27.4%), anxiety (23.5%), difficulty to concentrate (19.6%) and short attention span (19.6%).
The above findings suggest that drug use by parents has several negative consequences to their young children mainly on an emotional and behavioural level. Thus, in order to prevent these psychological problems and to take care of them, adequate prevention and counselling programmes need to be developed.
9.6.3 Parents of drug users
Family programmes are well developed in Greece, since drug use is considered to concern the whole family system. Within this framework, the duration of family therapeutic programmes is about the same with the duration of drug users’ treatment. Qualitative evaluation results from all family programmes suggest that parental involvement in treatment motivates drug users to seek therapy, enhances their therapeutic outcome, improves relationships and functionality within the family, and promotes relapse prevention.
In 1999, the KETHEA’s six family programmes provided its services to more than 5,000 parents and relatives of drug users. Out of them, 3,674 persons participated in the short-term seminars organized by the family programmes, while 2,617 persons participated in long-term family therapy groups.
A special service for parents is provided since 1985 by the Association for Encountering Drug Dependency (SAT). The programme uses several models, such as the psychodynamic and the systemic approach, the communicative model as well as role-playing and drama-therapy. In 1998, eighty persons received its services.
9.6.4 Drug use at the workplace
Although no concise policy plan for prevention programmes at the workplace has been developed yet, prevention centres at the local and regional level as well as other organisations (i.e. OKANA, KETHEA and Hellenic Institute of Hygiene and Safety at Workplace) implement such programmes on a regular basis. Their main target-groups are the following: Mass Media, local authorities, health professionals, professionals of the private sector (i.e. pharmacists, lawyers, personnel of tourist enterprises, banks’ personnel) and services of the
109 public sector (i.e. Greek Police, Military Force, Greek Mail Services, Greek Telecommunications Organisation, Public Electricity Agency).
Information and sensitisation of employees and employers on health issues as well as on drug and alcohol prevention are the main objectives of all respective interventions. Moreover, the programmes carried out at local level aim at professionals’ actualisation and involvement in community prevention programmes, so as for a local prevention network to be established. Many prevention interventions at the private sector, the media and the police and military services are organised after the sensitisation of the wider community by the prevention centres. Trade unions, also, provide the impulse for prevention programmes at their workplace to be implemented.
Evaluation of prevention initiatives at the workplace is quite limited. However, interventions at professionals and agencies at the local level as well as those addressing police officers and military services are systematically evaluated. Process evaluation for interventions at the military services has shown that the extremely large number of participants and the obligatory attendance to the seminars prohibit active interaction and integration of information. Moreover, outcome evaluation of a prevention programme that addressed police officers indicated that 90% of them accepted the importance of prevention as well as that they could play a significant role in preventing drug use/abuse.
Finally, the Drug Dependence Prevention & Health Promotion Centre «PYXIDA» has implemented since 1998 a prevention programme that was addressed to professionals and agencies from different fields. According to the evaluation results after a two-year implementation of the programme, participants appeared to be sensitised to the psychosocial factors that lead to drug use/abuse and to the importance of volunteers’ role in prevention. The latter was proved by the fact that many of the participants decided to form a group of volunteers, which has already taken action on organising various prevention activities with the aim to inform and sensitise the local community (see also Chapter 9.1.4 Community Programmes).
9.6.5 Ethnic minorities
Although a great number of immigrants and refugees came in Greece during the last decade, no specialized treatment programmes for this population have been developed yet. However, an increasing number of prevention programmes addresses minority groups and socially excluded people, while many sensitization activities take place, under the initiative of therapeutic programmes and volunteers associations.
The Hellenic Centre of Intercultural Psychiatry and Care continued its programme entitled “Combatting social exclusion in the context of substance abuse”, which is implemented since 1996 (see also 1998 Annual Report). The objectives of this programme are the following: a. information and sensitization of the local and mainly of the school community on prevention of drug dependence and on promotion of health, b. social rehabilitation and vocational
110 guidance of adolescents belonging mainly in socially excluded groups, and c. research on mobile populations and on socially and culturally differentiated groups, especially in terms of their attitudes towards health issues.
In 1999, the local communities where the programme is implemented requested from the Centre to address 8,000 students, parents and teachers. After choosing the most vulnerable and problematic groups, the Centre trained 100 teachers, it sensitized 300 parents and it intervened in 250 secondary students of high-risk. Moreover, the Centre assisted 250 socially excluded families in their contacts with public services, while it provided the following services: a. material support to 120 families with serious survival problems, b. counselling and/or psychiatric support to 70 persons, c. vocational guidance to 35 persons (20 male adolescents and 15 women aged 18-25 years old), and d. workshops on creative occupation to 100 children outside school as well as to women aged 15-35 years old. A subsidized training seminar was also organized for 20 unemployed ROMs in co-operation with the National Organization of Welfare.
According to the evaluation results, the programme contributed to several positive developments in micro and macro level. In particular, the successful cooperation between the prevention agents and the local community assisted in the effective exchange of information, while the residents changed their attitudes towards the social welfare services, which resulted to an increased access to them. In macro-level, the programme promoted the development of new social structures and networks, which aim at improving the living conditions for socially excluded and minority groups.
The Information & Prevention Centre Against Drugs of the Municipality of Xanthi – a region where many people from the Muslim minority live – organized in 1999 an educational seminar on health promotion issues. The group of the twenty participants consisted of Christian and Muslim teachers of secondary education. Also, the four Drug Prevention Centres of Attica address their services to minority groups living in the wider area of Athens, aiming to reduce factors leading to social marginalization and exclusion.
An initiative of high importance in 2000, was a two-day happening of cultural activities, organized in Athens by the KETHEA therapeutic programme “DIAVASSI” in cooperation with nine volunteers associations. This happening aimed at sensitizing the wider community about the effects of social exclusion on individuals’ well being and on the quality of interpersonal relationships. Drug users and cultural minority groups jointly undertook the various cultural activities, through which the message of cooperation among the different socially excluded groups despite their differences was conveyed.
Apart from prevention and sensitization interventions, research studies on minorities were also developed. In the context of the postgraduate course entitled “Social Exclusion and Minorities” of the Panteion University in Athens several studies were conducted in 2000 regarding the issue of minorities and drugs. Their findings will be available at the beginning of next year.
111 Despite the fact that no specialized treatment programmes for minority groups are available, immigrants or people belonging to different cultures are able to ask for drug therapy at the existing treatment services. Results from the two substitution programmes in Athens showed that 5% (10 persons) of their clients were not Greek (Douzenis et al. 2000). In particular, two of them were E.U. citizens, one was from the former Soviet Union and the rest were ROMs. Out of the ten clients being from different cultures, only four remained in treatment. Cultural differences appear to be the main reason for the high percentage of dropouts from treatment by drug users belonging in minority groups. Similar findings have been reported from KETHEA therapeutic programmes, where culturally different clients have been increased during the last years. For example, the number of people from minority groups, who asked for therapy at the therapeutic programme for adolescents “STROFI” in 1999, was fourfold compared to 1998 (STROFI 2000).
In order to respond to minorities’ needs more effectively, KETHEA plans to develop in the near future a specialized therapeutic programme entitled “Transitional Integration Centre of Special Social Groups”. This Centre will include streetwork interventions in the Athens greater area, a counselling programme aiming at psychosocial support, a hostel and a drug-free therapeutic programme. Moreover, it will provide training to professionals belonging in ethnic minorities in order for them to work in the Centre and it will cooperate with other health and social agencies, so as for a support network to be established (Poulopoulos in press).
9.6.6 Self-help groups
Narcotics Anonymous (NA) is an international, non-governmental organization addressed to both men and women drug users, with the only requirement for them to wish to stop taking drugs. Apart from the support groups addressed to drug users, NA also organizes open meetings for the lay public.
Regarding the evaluation of their interventions, this is difficult to be conducted, since they do not keep records with their members. However, an indicator of positive value is the fact that the number of the drug users who participate in the NA groups is constantly increased at annual basis.
Self-help groups are also organized for youth at risk and for experimenting drug users by the “Hellenic Church Mission of Support to Socially Excluded and Drug Dependent Persons”. This mission, which is implemented by young former drug users, includes streetwork interventions in Athens, Thessaloniki and Patras and it also provides counselling services.
9.6.7 Alternatives to prison and prosecution
Pecuniary penalties and confinement in specialized treatment prison units after the offender’s acquiescence are the alternatives to prison for drug law
112 offenders. The first specialized detoxification unit for drug dependent prisoners will be inaugurated in Thiva (Central Greece) in the near future.
Moreover, the Minister of Justice has planned a pilot programme providing among others for the entering into force of inactive legal provisions alternative to prison, such as labour of public benefit.
Prosecution alternatives are decided by the Public Prosecutor’s office, which in case of drug addicted offenders can decide for: a. the confinement of the offender in a specialized treatment prison unit as alternative to time spent for temporary detention or serving of a sentence, and b. the permanent postponement of penalty imposition in case the offender is attending a legal detoxification programme.
10. QUALITY ASSURANCE
10.1 Quality assurance procedures
The promotion of quality at the demand reduction field, especially at the prevention centres, was the first and foremost priority in 2000. Formal requirements for quality assurance in the prevention programmes had been devised since 1996, when the first prevention centres were established by the OKANA in co-operation with the local authorities. However, practical difficulties (i.e. bureaucracy) or lack of sufficient support, resulted to considerable deficiencies at the implementation of the prevention programmes and impaired the quality of the provided services. With the aim to ameliorate this particular situation and to ensure quality and effectiveness of prevention interventions, policy makers re-formulated in 2000 a comprehensive statutory framework with specific criteria and requirements.
In particular, the current formal requirements can be classified in six major categories, as follows:
· Number and professional background of the prevention centres’ personnel
· Qualifications that prevention agents should have in order to be adequate enough to implement quality prevention programmes
· Systematic participation in training programmes, which will be organized by specialized institutions
· Evaluation of all prevention interventions
· Continuous supervision of the prevention centres and co-ordination of the local authorities in their role to ensure their development
· Active and systematic co-operation among all prevention centres nationwide.
113 Each of these requirements consists of various criteria, which are portrayed in details on Table 18.
The primary rationale of the specific criteria, presented on Table 18, is based on the initial policy plan concerning prevention centres, which was formulated in 1996, as already being said. However, their precise conceptualization stems from the existing difficulties and needs that prevention centres stated at a relevant evaluation study (see Chapter 10.2 Evaluation).
114 Table 18: Specific criteria in the prevention field according to the formal requirements for quality assurance
Formal Specific Criteria Requirements - Each prevention centre’s personnel should consist of five Prevention professionals at least: one Scientific Director, three more agents’ number scientists and one secretary. and background - The background of the scientific group should be related to human and/or social studies, with one person at least being Psychologist. - All prevention agents should have a Bachelor’s degree in Psychiatry, Psychology, Sociology, or in Social Work. Prevention - Preference is giving to those having Master’s degree, previous agents’ employment in prevention or therapeutic agencies, training in a qualifications specific psychotherapeutic method, training in prevention (at least 100 hours) and good knowledge of a foreign language. - The scientific director should further have a three-year previous experience in prevention or therapeutic programmes or a five-year one in their specialty. - All prevention agents should participate in a three-month training programme, which aims at promoting a common philosophy and methodology in the prevention field nationwide. - Continuous participation in training seminars, which concern: Training a) implementation of existing and new educational materials, b) planning and development of interventions in specific populations (i.e. army), and c) self-evaluation. - Co-ordination of all the training agencies by a central body, so as overlaps and confusion to be avoided. - Development of new educational materials, so as prevention methods and interventions to be enriched. - Prevention centres should evaluate internally the whole range of their interventions as well as their three-year work plan. - Training agencies should provide prevention centres with the Evaluation necessary scientific instruments and know-how for the evaluation purposes. - Training institutions will be also evaluated for the quality and effectiveness of their programmes. - External evaluation of the prevention programmes is envisaged in the near future. - A central co-ordination body should systematically implement Supervision of a two-way supervision schema: supervision of the prevention prevention work from planning to outcome and supervision of the local centres and co- authorities’ role in supporting and funding prevention centres. ordination of local authorities - Continuous monitoring and immediate response to the prevention centres’ difficulties and needs. - All prevention centres should have access to the Internet. Co-operation Electronic chat groups and databases with information on prevention programmes will be provided soon and prevention centres should use them. - Prevention agents should participate in meetings and conferences so as to exchange experience.
115 Besides the training institutions, which are responsible for supporting prevention centres in educational and scientific issues, the OKANA as the central co- ordination body on drugs and the Greek REITOX Focal Point will be expected to play a crucial role in monitoring and assessing quality of the prevention programmes.
The following instruments are those currently applied in quality assurance at the prevention field:
· The “Exchange on Drug Demand Reduction Action” (EDDRA) questionnaire
· Evaluation questionnaires included in the educational packages, which are used at school and family prevention programmes
· Evaluation standardized instruments as well as self-constructed questionnaires by the prevention centres
· Annual reports submitted to the OKANA
· Feedback that is provided in meetings between prevention agents, training institutions and supervising bodies.
The current situation in the treatment field is quite different from the one existing for the prevention centres. In particular, a single homogenous schema for quality assurance in drug therapy has not been implemented yet. This is due to the fact that priority was given to prevention centres on the one hand, and on the other because treatment programmes differ substantially in terms of their philosophy, theoretical principles, therapeutic methods and organizational framework. Thus, the establishment of common formal requirements for quality assurance in this field appears to be a rather perplexing task.
However, with the opportunity of the Workshop on “Evaluation of Psychoactive Substance Use Disorder Treatment”, organized by the WHO, the OKANA and the Greek Focal Point in March 1999, a provisional national plan for evaluating treatment services was structured for the first time (Chart 1). This plan has been formulated according to the Guidelines of the WHO/UNDCP/EMCDDA Workbook series and the majority of the therapeutic programmes approved it. Although it has not been implemented in practice yet, this plan constitutes a formal common basis for future action.
116 Chart 1: Provisional National Plan for the Evaluation of Treatment Services
Promoter Partners (Ministry of Health, Scientific and Technical Components: (OKANA, F.P., Others) OKANA, Therapeutic Infrastructure Programmes, NGO’s)
Proposal preparation - Debate Scientific and Technical Core activities: (Rationale) - Consultation Framework - Framework of implementation
- to sensitize - to ensure commitment - to sustain & promote Short-term objectives: - to stimulate involvement - to promote co-operation evaluation - to ensure means, funds - external evaluation
Medium-term - to seek general improvement of quality objectives: - to assess cost-effectiveness
- to improve the overall plan of treatment in terms of needs, community and treatment policy Long-term objectives: - to meet drug users’ needs more effectively - to ensure funding
117 At the present, each specialized therapeutic agency has developed their own specific principles, criteria and instruments for quality assurance of their services. Still, all of them should comply with the following minimum requirements:
· To maintain and to provide a comprehensive and clearly defined framework of treatment services, which must function under law permission. · To occupy specialized and highly trained personnel or former drug users with adequate prior education in counselling/treatment issues · To actively care for the continuous improvement of their services through participation in national and international training programmes, conferences and seminars · To participate in or to conduct research studies relevant to treatment issues · To keep records for their clients’ drug use patterns and their socio-demographic characteristics and to monitor their psychosocial development. When requested by policy makers or research institutions, to distribute the data available regarding either their clientele or their programmes. · To be supervised by the Organization Against Drugs (OKANA), except of KETHEA’s treatment programmes.
Optimally, treatment agencies should also conduct internal or external evaluation of their services on a constant basis. However, several discrepancies exist on the extent and the type of the evaluation studies as well as on the methodology used among the various treatment agencies.
10.2 Treatment and prevention evaluation
Two major initiatives played a crucial role in promoting evaluation at the drug demand reduction field in 1999-2000. The first one was the WHO Workshop on “Evaluation of Psychoactive Substance Use Disorder Treatment”, which was held in March 1999. The second was a national evaluation study, conducted from December 1999 to February 2000, on the difficulties and needs of the forty prevention centres that had been founded by OKANA up to the beginning of the study. These two events constituted the basis for a policy on evaluation to be planned – in the case of treatment programmes - or to be implemented in the case of prevention programmes (see also Chapter 10.1 Quality assurance procedures).
The evaluation study carried out by the OKANA and the Focal Point at the prevention centres nationwide, was aiming at: a) assessing the various difficulties in planning, implementing and evaluating primary prevention programmes, b) determining the reasons for the existence of these problems, c) reporting the educational and scientific needs of the prevention agents, and d) detecting possible solutions for overcoming the existing difficulties. Two self-constructed questionnaires with closed and open questions were administered to the prevention agents group and to the president of the local authorities board of each prevention centre.
118 According to the findings of this study (Paralaimou et al. 2000), some of the main difficulties that prevention centres confront concern the following:
· the lack of funding and support by the local authorities, which mainly stems from their lack of sensitization in the importance of prevention centres’ role at the local communities · the insufficient co-operation between the OKANA and the prevention centres, which appears to result from the decreased number of OKANA’s personnel and from the existing bureaucracy · the difficulty prevention agents have to put in practice what they have been trained in · the lack of training and of experience in the implementation of evaluation studies.
Regarding evaluation, 64.7% of the thirty-eight prevention centres, which participated in the study, reported that they have difficulties in conducting evaluation of their programmes. More specifically, lack of adequate training and expertise was mentioned by nearly the majority of the centres as the main difficulty in conducting the three types of evaluation: planning evaluation (76.9%), process evaluation (77.8%) and outcome evaluation (40.0%).
On the grounds of these findings, a concrete and methodical evaluation policy started to be implemented. Training in self-evaluation has been posed as the first priority. Specific institutions with prior experience on the issue (i.e. Educational Centre for the Promotion of Health and the Prevention of Drug Abuse) were assigned to be responsible for prevention agents’ evaluation training. This will be organized on a continuous basis with emphasis on regular mutual feedback and adequate response to the current needs. Moreover, OKANA has systematized, through the upgraded responsibilities of a scientific committee, the supervision processes regarding the performance of the prevention centres and the role of the local authorities. Finally, initial efforts (i.e. ensuring funding and employing personnel) were made for external evaluation to be put on.
The University Mental Health Research Institute (UMHRI) in co-operation with the Directorate of Secondary Education of the Prefecture of Ahaia conducted another study in 1999-2000 in the context of evaluation research. The aim of this study was to measure the outcome of the health promotion programmes in schools dealing with drug prevention issues, which were implemented in the region within the academic year 1997-1998. The sample of the study included 500 students of the fifth and sixth grade of the high schools where the health promotion programmes were implemented and a control group. The tools used were the ESPAD questionnaire and a specially designed questionnaire for teachers’ opinion. The findings of this study will contribute to possible changes and modifications to the health promotion programmes that are implemented nationwide by the Ministry of Education.
Although an evaluation policy in the treatment field was planned in 1999, it has not been implemented yet (see also Chapter 10.1 Quality assurance procedures). Nevertheless, the WHO Workshop on Evaluation of drug treatment contributed considerably to promoting evaluation of therapeutic programmes. In particular, three therapeutic agencies initiated evaluation interventions after the Workshop, according
119 to the specific methodology proposed in the Workbook series. Moreover, the Workshop advanced the evaluation processes already implemented by some therapeutic programmes through their modification and enrichment.
Evaluation practice in drug treatment services appears, though, to be rather fragmented and unmethodical. With the opportunity of the WHO Workshop and of the tentative “National Plan for the Evaluation of Treatment Services”, representatives of all the treatment agencies nationwide agreed that in order for a comprehensive and systematic treatment evaluation to be implemented, the following requirements should be covered:
· to ensure funding for evaluation purposes · to precisely define the co-ordination, planning and implementation procedures in order for a global evaluation schema to be implemented in all treatment agencies. This determination should be made either by a central co-ordination body (i.e. OKANA) and/or in co-operation with the treatment institutions. · to clarify the objectives of such a national common evaluation policy as well as the means the evaluation results will be used, so as to be of the treatment agencies’ benefit · to promote training in evaluation issues, which should be organized on a systematic basis and within a comprehensive and specific scientific framework.
Indeed, training in treatment evaluation is scarce and unsystematic. Apart from the WHO Workshop on “Evaluation of Psychoactive Substance Use Disorder Treatment”, which was organized by the OKANA and the Focal Point, the only other educational programme developed in 1999 was the one called “Social Planning and Social Policy”. This programme, which is co-ordinated by the Therapy Centre for Dependent Individuals (KETHEA) in co-operation with the Social Policy Department of the Boston College, aims at assisting participants in planning, implementing and evaluating comprehensive action plans. However, a growing interest in treatment evaluation training is exhibited through the organisation of relevant conferences (i.e. “Evaluation of drug treatment agencies”).
The KETHEA is the only therapeutic agency that conducts systematic evaluation of its services on a regular basis. This is done both internally and externally. The internal evaluation is based on the Management Information System, which collects clinical, administrative and financial data on a monthly basis across KETHEA’s programmes nationwide, and on the Continuous Improvement Quality Tool that is implemented on an annual basis. A committee of three experts does the external evaluation. The external evaluation includes: a) questionnaires administered to drug users and their families, b) focus group interviews among members of the personnel, drug users and their families, c) interviews with employees and drug users, and d) participant observation of the experts committee. The satisfaction of the provided services, the effectiveness of the treatment programmes, ethical aspects and the safety and hygiene in treatment centres are some of the main issues that are under the scope of external evaluation (KETHEA 2000).
In 1999-2000, the KETHEA was also active in conducting research studies related to evaluation issues in the prevention and the treatment field. General principle of these
120 studies is to make the best possible use of their results so as to improve the quality of the provided services, but also of the research methods per se (see also Chapter 10.3 Research).
10.3 Research
Research in the demand reduction field is continuously developing, on the grounds of the necessity to support prevention and treatment interventions upon specific research findings. Still, research in the treatment domain is more developed in comparison with the existing situation in the prevention field. This is mainly due to the fact that prevention centres have been established recently (i.e. within the last four years) and because priority was given to the implementation of prevention programmes at the local communities rather than to researching. However, a growing interest in conducting prevention research studies has been observed in 1999-2000. Moreover, special attention was paid on evaluation projects regarding treatment programmes.
The objectives, structure and other information about the research projects that either started or were in progress in 1999-2000 are presented below. They are classified according to the three levels of prevention (primary, secondary and tertiary), whereas evaluation studies are portrayed in a distinct category.
Research projects in Primary Prevention
1. “Pilot study on the cross-sex relations in fourth grade high-school students” (1998-2000) Research Agency: The “PROTASI” Movement in collaboration with the Directorate of Secondary Education, The Athenian Center of Study of the Human Being (AKMA) and the University of Patras Sources of Funding: Ministry of Education (Health Promotion Department) and the National Institute of Youth Objectives: To explore students’ needs regarding cross-sex relations and sex education issues, aiming at a more comprehensive implementation of the relevant health promotion programmes Sample: 278 fourth grade high-school students from two schools of the Prefecture of Ahaia. Method: Questionnaires.
2. “Survey on the social needs of young people who live in the region of the Creative Occupation Center of the “PROTASI” Movement: The need to establish and to support a Youth Café” (1999-2000) Research Agency: The “PROTASI” Movement in collaboration with the Creative Occupation Center Objectives: to explore the young people’s leisure-time activities and to detect their beliefs, in order for the Youth Café to be not only a meeting-point but also a place where they could develop creative activities that will meet their needs
121 Sample: Young people aged 16-25 years old from the region, representatives of local agencies, key-persons of the district, members of the “PROTASI” Movement and members of the Creative Occupation Center aged 13-17 years old Method: Participant observation, semi-structured interviews with representatives of local agencies and questionnaires administered to the other subjects of the sample.
3. “Research on the use of addictive substances among the students population of those prefectures where Prevention Centres are established by the OKANA” (1999-2000) Research Agency: University Mental Health Research Institute (UMHRI) Sources of Funding: The Organisation Against Drugs (OKANA) Objectives: To study the prevalence of the addictive substances use among high school students as well as the related psychosocial factors, in 26 prefectures where Prevention Centres operate. Research data will assist prevention agents to plan their interventions in more accordance with the local needs. Sample: A representative sample of high school students (i.e. fourth and fifth grade) from each prefecture, which will constitute 5.000 subjects overall. Method: The European questionnaire of the ESPAD study, translated and adapted in Greek.
Research projects in Secondary Prevention
1. “Substitution Therapy in the EU” (1999) Research Agency: The OKANA in collaboration with the Observatorio Epidemiologio Regione Lazio (Italy) and the National Addiction Center (UK) Sources of Funding: The European Union and the OKANA Objectives: Description of the substitution programmes that are being implemented in the EU countries and review of the related literature Sample: Substitution Units of the OKANA.
2. “Drug use among prisoners” (1999) Research Agency: The OKANA in collaboration with the Ministry of Justice Sources of Funding: The European Union and the OKANA Objectives: To collect up to date information regarding drug use among prisoners in order to plan new effective policies in prisons about: a) drug demand reduction interventions, b) harm reduction programmes, c) promotion of a healthy way of living, and d) training of prison’s personnel. Research data will also assist in re- examining the current legislation regarding possession and abuse of illegal drugs. Method: Administration of questionnaires to prisoners and to prison’s personnel.
122 3. “Study on the intravenous drug use – Phase B” Research Agency: The OKANA and the WHO. Sources of Funding: The OKANA and the WHO. Objectives: To promote harm reduction from the intravenous use of psychoactive substances. Sample: 400 drug users (200 users who were admitted in a therapeutic programme within the last 30 days and 200 street-users). Method: Administration of questionnaire.
4. “Socio-demographic characteristics and patterns of drug use among those drug users who approached the KETHEA’s Counselling Centers from 1995 to 1999” (1999) Research Agency and Source of Funding: KETHEA Objectives: To compare the last five-years’ data, in order to detect new trends of drug use and changes in the socio-demographic characteristics. Sample: Drug users who applied for therapy in the KETHEA’s Counselling Centers from 1995 to 1999. Method: Interviews based on the “First Treatment Demand Indicator” (Pompidou Group).
5. “Socio-demographic characteristics and patterns of drug use among those drug users who approached the KETHEA’s Counselling Centers in 1999” (1999-2000) Research Agency and Source of Funding: KETHEA Objectives: To explore the needs of drug users who seek help and to improve the provided services. Sample: Drug users who applied for therapy in the KETHEA’s Counselling Centers in 1999. Method: Interviews based on the “First Treatment Demand Indicator” (Pompidou Group).
Research projects in Tertiary Prevention
1. “Research on the dimensions of social exclusion” (1999-2000) Research Agencies: The KETHEA and the CEIS (Italy) in collaboration with the Privatklinikkey Gundderuplund (Denmark) and the Warwickshire Probation Service (UK). Sources of Funding: The European Union and the KETHEA. Objectives: To investigate the factors that associate drug addiction with exclusion from the labour market and with social exclusion, in order to develop effective methods for their combating as well as networks for drug users’ reintegration.
123 Sample: Three different groups of 75 drug users from each participant country (Greece, Denmark, Italy, UK). The three groups are: a) drug users who had a job and they lost it because of their dependence, b) drug users with delinquent behaviour, who are socially excluded, and c) parents and relatives of the second group. Method: The qualitative method of “life stories”.
Prevention and Treatment Evaluation Studies
In addition with the two evaluation studies regarding prevention centres and health promotion programmes conducted in 1999-2000 (see Chapter 10.2 Treatment and Prevention Evaluation), the following evaluation projects were also done:
1. “Evaluation of the pilot health promotion and prevention programme in the Unified Multi-field High School of Piraeus” (1997-1999) Research Agency and Source of Funding: KETHEA Objectives: To evaluate the results and efficacy of the programme and to make suggestions for the implementation of similar programmes in the future. Sample: High school students and their teachers Method: a) questionnaires in experimental and control groups (pre-test, post-test method), b) two focus-groups, one with students and one with teachers, c) diary of the programme, and d) the Greek version of the “STEPP” instrument (“Staff/Team Evaluation of Prevention Programmes”, U.S. Department of Health and Human Services, Rockville, Maryland 1987).
2. “Evaluation of the pilot health promotion and prevention programme in the 28th Primary School of Piraeus” (1998-1999) Research Agency and Source of Funding: KETHEA Objectives: To evaluate the results and efficacy of the programme and to make suggestions for the implementation of similar programmes in the future. Sample: High school students and their teachers and parents. Method: a) questionnaires, b) focus groups with parents and teachers, c) diary of the programme, and d) students’ papers.
3. “Outcome effectiveness research of the KETHEA’s therapeutic communities” (1999-2001) Research Agency: The KETHEA and the Department of Sociology of the Hellenic National School of Public Health in collaboration with the University of Pennsylvania (U.S.). Objectives: To evaluate the effectiveness of the therapeutic programmes and to locate the parameters that enhance the therapeutic result. Sample: 500 individuals who spent even one day in the KETHEA’s therapeutic communities from 1994 to 1995.
124 Method: Field-study based on semi-structured and in-depth interviews.
4. “Clients’ satisfaction from the services of KETHEA” (1999-2000) Research Agency: The KETHEA in collaboration with the Department of Sociology of the Boston College (U.S.) Objectives: To improve the policy and the provided services of the KETHEA. Sample: The total number of clients (1328 individuals) who were in the treatment services of KETHEA for at least a limited period of time. Method of Data Collection: Self-administered questionnaire.
Apart from the above research projects, a study of special interest is the one conducted by the Physiology Laboratory of the Medical School of the University of Ioannina in collaboration with the Drug Dependence Treatment Unit (Psychiatric Hospital of Thessaloniki) and the Counselling Centre for Combating Drugs of Ioannina. According to the results, when heroin users who are under the withdrawal syndrome are provided with large quantities of Vitamin C, withdrawal symptoms either do not develop or they decrease considerably. On the grounds of these promising findings, the research team suggested that Vitamin C could replace the drugs currently prescribed for combating the withdrawal syndrome.
As it may have become obvious from the information previously provided regarding the current demand reduction research projects, the relations between research and drug services are robust and reciprocal. In many cases, the research projects are undertaken by the drug services in collaboration with national or international research institutions, so as to ensure the scientifically sound methodology and development of the study. On the other hand, when research agencies are responsible for conducting demand reduction studies, these are always done in close co-operation with drug prevention or treatment programmes. This kind of co- operation between research and drug services prevail not only because it is easy to find the samples of the studies (i.e. drug users) at the drug services, but also because it appears to have been acknowledged that research findings contribute to the improvement of the drug services. However, co-operation between researchers and health professionals in the drugs field needs to be further reinforced.
The latter is also proved by the fact that many research projects are funded by the drug services themselves (i.e. KETHEA). Other sources of funding are national governmental and non-governmental bodies (i.e. Ministry of Education, National Institute of Youth, OKANA), international organizations (i.e. WHO) and the European Union. The amount spent on research by the OKANA in 1999 was 130.000 Euro. However, a global estimation on the amount spent on research by the different sources at the national level is not available yet. In order to fill these gaps in information provision and to promote exchange of experience in the research field, the Greek Focal Point has developed a relevant electronic database, which will start to operate at the beginning of 2001.
There are two types of training in demand reduction research: a) seminars organized by national or international research institutions to professionals in the drug field, for
125 the purposes of a particular study to be conducted, and b) in-service training according to the needs of the drug agency. Nevertheless, training in demand reduction research is rather unsystematic and it appears that it is up to the drug service’s willing to have training in research methods or not. Work overload from the therapeutic or prevention tasks, lack of time and feelings of inadequacy regarding previous knowledge of research methodology are the main obstacles that impede professionals from the drug field to get trained in demand reduction research methods. Thus, it seems necessary to develop a certain policy that will promote training in demand reduction research on a regular basis, which will consequently advance research in the demand reduction field.
10.4 Training for professionals
On the grounds of the promotion of quality assurance in the prevention field, training of prevention agents acquired a clear and concrete structure. Based on the results of the national evaluation study at the prevention centres and on the institutions’ previous experience in training programmes, the OKANA as the central supervising body of all prevention centres nationwide, defined which institutions will provide formal training in the prevention field and what type of training will be provided by each (Table 19: Structures and types of training in the prevention field).
In this vein, the Educational Centre for the Promotion of Health and the Prevention of Drug Abuse, which has a great experience in educating prevention agents, plays a main role in organizing training on a systematic basis, in co-operation with the other institutions that are delineated in Table 19. Apart from these institutions, other local educational agencies may also provide training services, unless overlapping is possible. In general, training focus on the three following aspects: a) self-evaluation, b) adaptation of a holistic prevention approach involving all sectors and social groups of the local communities, and c) implementation of new educational materials and use of new techniques.
126 Table 19: Structures and types of training in the prevention field
Training institutions1 Types of training Anthropos Athenian Institute Application of systemic theory and methods in the (AKMA) prevention field · Planning and implementation of school Department of Adolescents prevention programmes at the local community and Young Adults – Drug Dependency Unit “18 ANO” · Application of short-term secondary prevention techniques to drug users and their families · Three-month introductory training in prevention issues · Planning and implementation of school, community and family prevention programmes Educational Centre for the Promotion of Health and the · Planning and implementation of prevention Prevention of Drug Abuse programmes to specific target-groups (i.e. army, ethnic minorities, primary school children), in co- operation with other training agencies · Implementation of specific educational materials produced by the Centre · Self-evaluation of prevention interventions and of the three-year prevention work · Filling in the “Exchange on Drug Demand Greek REITOX Focal Point Reduction Activities” (EDDRA) and make good use of it in the prevention work · Evaluation methods and techniques Hellenic Centre for Planning and implementation of prevention Intercultural Psychiatry interventions to ethnic minorities and to culturally and Treatment different people Human Relations Research Application of systemic theory and methods in the Laboratory (EDAS) prevention field · Implementation of the educational material “Skills Therapy Centre for for the Primary School Child”, published by the Dependent Individuals Centre (KETHEA) · Application of short-term secondary prevention techniques to drug users and their families Application of research methods in the prevention University Mental Health field within the framework of specific studies Research Institute (UMHRI) conducted by the Institute
1 Training institutions are presented in alphabetical order.
A great number of new educational materials were published in 1999-2000 not only concerning prevention issues, but also regarding various aspects of drug abuse treatment. In particular, the Educational Centre for the Promotion of Health and the Prevention of Drug Abuse produced the following information material and training packages for professionals working at the prevention field:
127 · “Children’s games” (2000): This book is provided to primary school teachers and it is a translation of a Swiss educational material addressed to children aged 7-9 years old. The main subject is the conflicts that children of that age experience at cognitive, emotional and interpersonal level. · “Adolescents’ chats: Mental Health and Interpersonal Relationships” (2000): It was produced on demand of the Ministry of Education. It is addressed to secondary school teachers who implement health promotion programmes at their schools and to prevention agents working with adolescents aged 15-18 years old. · “A ship’s diary – Armenistis 1900” (2000): It is used by prevention agents who implement youth prevention programmes outside schools. It aims at assisting adolescents in the process of autonomy. · “Elements related to the addictive substances” (2000): This book is addressed to parents and teachers who participate in health promotion programmes regarding drug prevention. It provides basic information about the addictive substances (legal and illegal) as well as about the prevalence of drug use in Greece and the current law on drugs.
Moreover, the KETHEA translated in Greek the “Drug Education for Young Offenders” (TACADE) and it published the “Mental Health and Interpersonal Relationships” manual in collaboration with the Mental Health Organization for Children and Adolescents. This manual addresses students aged 11 to 14 years old. The “Addiction Counselling Competencies: The Knowledge, skills and attitudes of professional practice” was another publication of high importance, since a two-year training programme run by the KETHEA in collaboration with the University of California, is based upon this material. 52 professionals from the prevention and the treatment field have been trained up to now at this programme, while 50 more will participate from 2000 to 2001.
Further training programmes organized by the KETHEA in 1999-2000 are the following: a) “Relapse Prevention”, in collaboration with the Addiction Research Institute, b) “Introduction to groups”, in collaboration with the Department of Communication and Mass Media of Athens University, and c) Vocational training and counselling of former users (KETHEA 2000). Additionally, the Greek Focal Point organize on a systematic basis training programmes in the implementation of the “First Treatment Demand Indicator”, the “European Addiction Severity Index” (EuropASI), the “Exchange on Drug Demand Reduction Activities” (EDDRA) and the “Treatment Unit Form” (TUF).
Despite these efforts to promote training programmes for professionals working at the treatment field, the main direction currently is towards in-service training, which however is rather fragmented. In order to systematize training in the treatment field, the OKANA plans the regular organization of seminars for therapeutic agents as well as the education of doctors and psychiatrists in drug treatment issues. Moreover, within the next three years (2000-2003) the OKANA plans in co-operation with the Ministry of Education to introduce courses on prevention and treatment issues in the University schools of education and of health (OKANA 2000). Nowadays, the only available University education in drug-related issues is the two-year postgraduate course offered by the Psychology Department of the University of Thessaloniki. Also,
128 those University students of social sciences who are in the last year of their studies and who wish to have such training are able to get a six-month practical training at therapeutic agencies.
Evaluation of training programmes is mainly oriented on impact data (i.e. number of participants) and on qualitative information regarding process and organizational aspects. Thus, results on the efficacy of the programmes and statistical findings are quite limited. The Educational Centre for the Promotion of Health and the Prevention of Drug Abuse, the Greek Focal Point and the KETHEA systematically conducts evaluation of their training programmes.
The Educational Centre for the Promotion of Health and the Prevention of Drug Abuse has trained up to now 203 prevention agents, most of whom are occupied at the municipal prevention centres. Also, it has trained 56 professionals, who work at the health promotion programmes organized by the Ministry of Education and 138 other professionals (police officers, lawyers, etc.). Evaluation results showed that training in specific educational packages and the practical application of theories are more effective than theoretical training in general prevention principles and techniques. Moreover, most of the participants mentioned that training assisted them in being able to implement prevention programmes, but they asked to have continuous supervision during the implementation of the educational materials.
The Greek Focal Point evaluated in 1999-2000 the WHO Workshop on “Evaluation of Psychoactive Substance Use Disorder Treatment” (see Chapter 10.2 Treatment and prevention evaluation) and the two seminars on the EuropASI questionnaire. According to the evaluation results of the training on the EuropASI, most of the participants valued the use of the specific instrument for research and evaluation purposes and they expressed their willing to administrate it on a systematic basis. Indeed, the EuropASI was administered after the training in all treatment programmes, representatives of which participated in the seminars. However, all of them mentioned that the training would be more effective if it lasted for more than two consecutive days. Finally, in 1999 the KETHEA designed and implemented a questionnaire to evaluate the results and efficacy of the two-year training programme entitled “Addiction Counselling Competencies: The Knowledge, skills and attitudes of professional practice”.
11. CONCLUSIONS: F UTURE TRENDS
Based on the evolution of new interventions and programmes as well as on the national policy on drugs suggested by the OKANA in 2000, the main future trends identified are as follows:
· Drug-free programmes for adult drug users will be expanded nationwide with the aim to cover the existing lack of therapeutic options at the local and regional level. · New multi-phase programmes aiming at adolescents and young adults will be developed, which will complement the work of primary prevention centres. · Substitution and maintenance units will be further expanded, with the result for the number of drug users in the waiting lists to be decreased.
129 · Specialised programmes for high-risk groups, such as immigrants and prisoners, will be implemented, in order to provide these groups with adequate and adjusted to their needs services.. · Vocational training and after-care services will become of higher importance and they will be enriched.
Apart from these trends that have emerged already, it appears to be necessary for outreach and low threshold interventions to be further developed, in order to become easier for drug users to establish initial contact with mental and health services. Special emphasis should also be given in the development of demand reduction initiatives within prisons, which currently are quite limited. Moreover, it seems important for primary prevention interventions to be systematised and also to be expanded in other areas, such as outside schools (i.e. recreational places) and at workplaces.
Another issue of outmost importance is the promotion of scientifically sound and systematic evaluation. Evaluation studies have already been initiated especially in the prevention field, however improvement in internal and external evaluation activities is considered necessary. Within this framework, training in evaluation issues and development of research will contribute significantly to this issue.
The most important issue in demand reduction field appears to be the reinforcement of co-operation among professionals as well as between the latter and policy-makers and researchers. Comprehensive co-ordination of the different agencies, systematic exchange of opinions and expertise, and methodical connection between practice, research and policy will contribute to the enrichment of all types of intervention. Within this framework, the cooperation between specialised drug programmes and general health services also need to be further strengthened.
130 PART IV
KEY ISSUES
131 12. DRUG STRATEGIES IN EUROPEAN UNION MEMBER STATES
12.1 National Policies and strategies
Greek legislative policy on drugs since 1987 when Law 1729 was enacted has been attempting a holistic approach to the problem by providing both legal and therapeutic confrontation. Having left behind the previous strictly repressive model, the introduction of the prevention model 13 years ago contributed to a more balanced approach with the emphasis put on repression and on prevention and treatment at the same time. As it has been argued, Greek drug legislation as a whole follows on the one hand the “medical/prohibitive” pattern and on the other the pattern “permitted/prohibited” according to each specific case. The latter pattern is being followed by the Greek legislation on drugs since the amendment of Law 1729/1987 in Law 2161/1993 that provided for the establishment of Experimental Substitution Programmes with the administration of methadone to addicted heroin users (Spinelli 1999).
One of the factors that differentiate Greece from other European countries - usually with higher prevalence rates of drug use- is that Greece is among the countries that follow the model of complete prohibition as regards drug use. Following a specific legal view, this is against both the Greek Constitution (1st paragraph of the 7th article) and the Penal Code (Article 14), according to which a punishment can be imposed on a citizen only in case of an action performed against someone else. In the case of drug use victim and victimizer are one and the same person (Chaidou 1995). Penalization of simple use in Greece seems to move beyond the United Nations Convention that was ratified in 1991 in Greece (Law 1990/1991) providing for the criminalization of possession, purchase and cultivation of drugs and psychoactive substances for personal use (Spinelli 1999).
However, since drug use is illegal in Greece a decisive key role in law enforcement is assumed by the judicial system. Courts and judges have been entrusted with the responsibility of discriminating between addicted and non addicted offenders charged for drug use and moreover between those charged for use and those charged for trafficking or dealing in the case of charges for possession of a certain amount of drugs. Both decisions are crucial for the determination of the sentence. Law provides that the characterization of offenders as drug addicted users should derive from an expert appraisement formed by a specialized detoxification center, an appropriate University sector or a medical jurisprudence service. This provision, however, is not in force, a fact that eventually leads to the creation of associated problems. Spinelli (1999), refers to the difficulties faced in discriminating between users and traffickers, since as it is indicated by a statistical overview of penalties imposed either on users or on traffickers, traces of inconsistencies in the determination of sentences are obvious. There are cases, where individuals convicted for drug use serve life imprisonment, although this is not the appropriate penalty according to the law, whereas there are also individuals convicted for trafficking and dealing on which more lenient penalties than expected have been imposed. The latter, as she states,
132 is mainly due to the fact that those offenders somehow achieved to be characterized as users as well. For discriminating between users and traffickers or dealers the exact drug amount possessed plays the decisive role. The law states that the determination of the drug amount that could be considered as possessed or exchanged for personal use depends on the respective ministerial decrees. Such ministerial decrees have not been issued yet and, thus, it is again up to the courts to decide on the severity of the offence.
Another difficulty faced within the judicial system is that case hearing proceeds at a slow pace due to the large amount of case files that should be tried. This, as has already been argued by the Public Prosecutor Association, does not provide a desired solution to the phenomenon of drugs where the prosecutors’ interventions constitute repressive measures.
Confrontation of the existing judicial problems are at the scope of the Minister of Justice proposals (see also Chapter 1.1 Political framework in the drug field) by the re-examination of some drug law offences, the reduction in number of trial postponements and the establishment of new courts. Moreover, the All-Party Parliamentary Committee in March 2000, included in its proposals the need of unification of all existing drug laws aiming to the overcoming of legislative gaps and to a flexible adaptation to specific subjects.
In the domain of demand reduction the current situation reflects a multi- faceted approach to the problem. In the mid 90’s three major steps have been taken within the three levels of prevention that reinforced the attempt of a holistic confrontation: the inauguration of the first prevention centers, the creation of the methadone substitution programmes and the implementation of major initiatives aiming at the reintegration of former users. Moreover, although abstinence from drug use as well as physical and psychological detoxification are the major aims of demand reduction activities, low threshold services have also been created to meet the need for harm reduction to users who do not attend a treatment programme.
Reinforcement and expansion of the above activities are in the core of the national strategy plan in the field of demand reduction. More specifically, in order to ensure the development and the effectiveness of the existing prevention centres nationally and to continue the establishment of new ones, OKANA plans to reinforce the supervision over the local authorities, in order to enhance productive collaboration between them. Further evaluation progress as well as improvement of inter-connection among the centres are also among the national strategy targets and were also proposed by the All- Party Parliamentary Committee. The Committee also argued for the more rapid development of health educational programmes within schools and their expansion to the first educational grades.
As regards therapy, included in the national plan are the expansion of all sorts of therapeutic programmes and the establishment of methadone maintenance programmes as it was also proposed by the All-Party Parliamentary Committee. The Committee proposed also the continuation of substitution
133 treatment with the administration of other substitutes besides methadone and the decrease of substitution therapy duration. However, the Committee stressed that substitution programmes should not be viewed as a panacea and that further development of drug-free therapeutic programmes was also imperative.
Repression measures are the second major part of national policy against drugs. Since law prohibits use, possession, trafficking and cultivation of drugs, repression forces that are constituted by the Police, the Port Police Corps, the Financial and Economic Crimes Office and the Customs are involved in the prosecution of the above considered crimes. However, of major importance is considered drug trafficking, especially now that it develops within the framework of organized crime. Greece has been repeatedly characterized as a “cross-section for drug trafficking” between Asia, the Balkans and the rest of West Europe. Thus, emphasis has been put on the frontier guard through the establishment of a specialized unit that comes under the police (see also Chapter 1.1 Political framework in the drug field). The All-Party Parliamentary Committee, moreover, proposed for stricter legal measures against drug-traffickers whereas as regards drug use there was disagreement among the members in reference to the degree of liberalization.
Concluding, the following remark appears as important. Due to lack of a clear- cut policy framework that should combine the different philosophies of the authorities involved at all the levels of confrontation (repression, prevention, judicial process) many difficulties are faced in practice when trying to approach the phenomenon of drugs. Drawing on interviews given by social workers of the street work programmes, for example, one could infer that cooperation between the police and those programmes is insufficient, since police occasional repressive interference results in the removal and the split of concentrated open drug scenes that constitute the target group of street work programmes. Moreover, sporadic arrests of such social workers on the streets, as suspects for drug dealing, have also been observed embarrassing their work. Such difficulties could be overcome if a legal framework for street work programmes was laid down and in general if a unified drug policy was followed. Although interministerial cooperation for unified drug policy planning and implementation is a legislative requirement, in practice cooperation and effective communication are hindered due to organizational structure differences and bureaucracy. OKANA has been entrusted an important role in regard to improving interministerial cooperation, although, as the All-Party Parliamentary Committee argued, to succeed in this task its institutional upgrade is considered as imperative (see also Chapter 12.2 Application of national strategies).
12.2 Application of national strategies
Policymaking and policy implementation are carried out at various levels of social life. Deriving from the Parliament and executed by the government, legislative policy is applied with the mediation of three central agencies: OKANA, the Central Anti-Drug Coordinating Unit and the Judicial System.
134 However, OKANA has also assumed the role of inter-ministerial co-operation and co-ordination.
OKANA was established in 1995 following Law 2161/1993 as a self-regulating legal entity under the Ministry of Health. Its aim is to plan and promote inter- ministerial co-ordination, to research into the drug problem as well as to make policy in regard to all levels of prevention.
According to the Law 2161/1993 primary prevention programmes should be approved by the Ministry of Health. Proposals and organization of such programmes can be carried out by OKANA as well as by the Church, the local authorities, trade-union and governmental or private agencies provided that all the appropriate proposals have been submitted to OKANA. As regards this last stipulation excepted are only the programmes that have been developed by KETHEA, which do not need OKANA’s approval.
Many authorities are actively involved in the domain of primary prevention: Ministries (of Health and of Education and Religious Affairs), OKANA, local governments, educational and research institutes and non-governmental organizations. Primary prevention policy is actualized through the implementation of respective programmes either by prevention centers or by other agencies to the overall population as well as through the implementation of health promotion programmes in schools.
Within the domain of secondary prevention the organizational infrastructure of activities’ implementation follows more or less a similar to the primary prevention pattern. According to Law 1729/1987 the until then specialized treatment units for drug addicts were placed among KETHEA’s programmes. Further to 1987 Law, the 1993 amendment (2161/1993) stipulated that the establishment and functioning of all non-profiteering treatment centers for drug addicts should be under the umbrella of the Ministry of Health, that grants the appropriate licenses following OKANA’s opinion. Entitled for the establishment of secondary prevention units are the local governments, charity unions, the Church, universities and natural or legal persons with similar aims. Moreover, all treatment units that would be established from there on should be placed under the supervision and control of the Ministry of Health executed by OKANA. Excepted are only KETHEA’s programmes.
Involved in the implementation of secondary prevention programmes is also the Ministry of Justice. Most drug addicted prisoners served hitherto their term at the Korydallos and Patra prisons or at the Korydallos Prison Psychiatric Hospital, where they received pharmaceutical treatment. Moreover, in collaboration with KETHEA, 18ANO and the “Narcotics Anonymous” the Ministry of Justice provided for voluntary programmes aiming at harm reduction and motivation to treatment. In 1999, Law 2721 was enacted that provided among others for the establishment of two detoxification units for drug dependent prisoners, one in Thiva (Central Greece) and one in Chalkidiki (North Greece). A Ministerial Decree has also been issued in 1999 providing for the organization of the therapeutic programmes that would be implemented within the established units (see also Chapter 1.2.1 Drug laws)
135 Tertiary prevention is developed within most of the units that activate in the domain of treatment. However, in reference to the reintegration of former drug users to the job market the Ministry of Labour since 1996 has been attempting the creation of job opportunities by subsidizing employers or new free-lancers ex-addicts. In particular, a Ministerial Decree issued in 1997 by the Minister of Labour provided for the subsidize of employers for the employment of 290 ex- addicts, ex-prisoners and young delinquents. Moreover, in 1997 the Minister of Labour issued a Decree providing for the subsidize of new free-lancers former drug addicts or former prisoners aiming at the creation of 70 job openings (See also Chapter 1.2.1 Drug laws).
Repression policy is applied by four public bodies that are answerable to three different Ministries: a) the Police (Ministry of Public Order), b) the Port Police Corps (Ministry of Merchant Marine), c) the Financial and Economic Crimes Office and d) the Customs (both under the Ministry of Finance). Members of these four drug-law enforcement authorities constitute the Central Anti-Drug Co-ordinating Unit, with administrative and co-ordinating responsibilities. The Central Anti-Drug Co-ordinating Unit is a national information unit responsible for collecting data on drug-related deaths, seizures and arrests, and for submitting appropriate recommendations to the Ministerial Directorates in charge for policy making.
One of the major drug law offences that are prosecuted by the law enforcement authorities and is attributed also to the geographical position of Greece is trafficking. Specialized prosecution units contribute to the confrontation of drug circulation within or through the country. Drug dealing or trafficking within the country is prosecuted not only by general police manpower but also by a police unit specializing in the fight against drugs. Moreover, the establishment of a frontier-police unit has reinforced confrontation of drug trafficking through the Greek frontiers, since among their main tasks is also the fight against drugs.
Co-operation among the law enforcement authorities takes place at the level of information exchange so as to enhance positive results in the domain of repression. National repression authorities, moreover, collaborate with international ones such as INTERPOL or EUROPOL under the scope of prosecuting the organized crime. However, co-operation between repression and prevention authorities is also stated, since all repression authorities co- operate with OKANA and the Ministry of Health. Collaboration with prevention authorities goes beyond the simple information exchange and refers furthermore to the training of policemen in prevention in order to assume preventive and informative roles as well.
Overall co-ordination among authorities responsible for drug issues - considered as necessary for the promotion of policy making- has been undertaken by OKANA according to Law 2161/1993. Indicative of the attempt to a holistic coordinated approach is the synthesis of the steering committee of OKANA. It consists of members from all Ministries competent in drug issues (Ministries of Health, of Public Order, of Justice, of Finance, of
136 Education and Religious Affairs and of Merchant Marine), from the Centre of Therapy for Dependent Individuals (KETHEA), from the Church and from local authorities. However, the All-Party Parliamentary Committee in his final report in March 2000 argued for OKANA’s institutional upgrade. The Committee considered that as a prerequisite for OKANA to become an intermediary organization between the state and the NGOs and so that inter-ministry coordination is actually secured. Change of OKANA’s legal basis should lend it prestige, administrative autonomy and flexibility.
Moreover, the Committee considered the governmental financing for demand and harm reduction activities as inadequate. What was proposed was a significant rise of the State Budget funds in combination with the intensification of the attempt to secure funds from other governmental and non-governmental sources as well.
12.3 Evaluation of national strategies
An overall evaluation of national strategies to combat drugs is quite difficult, since, although a number of activities has been developed at every level of confrontation (repression, prevention, judicial process), there exists no clear- cut policy framework that combines the different philosophies of the involved authorities.
However, OKANA (2000) has made it clear that promotion of evaluation is among his main goals for the next three years. More specifically, the systematic identification of information gaps aiming at a better drug-strategy planning is considered of major importance. Under this scope research and systematic use of research findings will also be promoted. OKANA has been already considering the above as a priority by supporting the National Focal Point, by carrying out studies and research projects in the programmes under his umbrella as well as by funding epidemiological research projects carried out by other agencies. Moreover, to improve research and evaluation planning and coordination OKANA will enact a Department of Research and Evaluation.
Prospects and prerequisites for the reinforcement and the broadening of his goals have also been set by OKANA. The expansion of his subject to licit substances as well as further de-centralization and participation of more local communities stand as necessary prospects. However, political support, functional flexibility and enhance of state or private funds are considered as prerequisites for the efficient implementation of OKANA’s plan.
137 13. COCAINE AND BASE/CRACK COCAINE
Indications that cocaine use has increased in the last years is coming from various sources of information.
13.1 Different patterns and users groups
13.1.1 Epidemiological data
In the epidemiological studies in the general and the high-school students population in 1998 revealed the increase in cocaine/crack use. The percentage of high-school students who reported cocaine/crack use in 1998 was 2%. In the general population 2.5% among those aged 18-35 years in 1998 had used cocaine/crack.
Multiple logistic regression analysis was employed to examine the risk factors of cocaine/crack use, using cannabis users as reference group in the high- school student population.
According to the results the most significant risk factor for cocaine/crack use relatively to cannabis was use of tranquilizers or sedatives by their siblings (OR= 18.9, p<0.001)
Other significant risk factors were: · close friends using tranquilizers or ecstasy (OR= 3.8, p<0.05 and 4.6 p<0.01, respectively) · father’s death (OR = 4.3 p<0.001) · suicide attempts (OR = 3, p<0.001), and · exhibiting antisocial behaviour (OR = 2.7, p<0.01)
Less important factors were police arrests, running away from home and being a boy.
13.1.2 Data from dependent individuals
According to data from the Treatment Demand indicator, cocaine use has increased in the last 5 years; in 1999 cocaine use was reported by 14.8% of drug users who requested treatment, compared to 10% in 1996.
Cocaine users seem to prefer out-patient treatment services; 2.4% of clients requesting treatment from the out-patient services reported cocaine as their main substance of abuse, while the equivalent percentage in the in-patient units was 1%.
138 Of the cocaine users clients in 1999, the vast majority reported smoking (95.9%) and by mouth (49.7%) as routes of administration. A large percentage had a stable job (42.5%), while 6.2% were university graduates.
According to data derived from the research conducted in recreational places in Athens in 1998, among club/party goers cocaine is the most popular stimulant (10.1%). Its use in the different music scenes in Greece varies greatly; the higher percentage is shown among young people who prefer the Trance music scene (26.1%), followed by those who frequent the House and the Rock scene (10.7% and 10.4%, respectively). A small minority of the young people who prefer the Greek Popular scene reported cocaine use (2.7%).
13.2 Problems and needs for services
Studies investigating health or social problems of cocaine users as a separate group have not been conducted in Greece as yet, probably because the increase in its use has been identified only recently.
13.3 Market
13.3.1 Purity and Price
The National Chemical Laboratory analyses samples of seized quantities of drugs. According to them, cocaine is a white or almost-white fine powder with a characteristic odour; sometimes it contains hard colourless crystals (“rock cocaine”).
Cocaine adulterants do not change its physical appearance as they are also white. The adulterants most frequently found in cocaine are: · By-products: Ecgonine, Benzoylecgonine, Methylecgonine, Cinnamoyl- cocaine. · Pharmacologically active substances: non-controlled local anaesthetic substances (Procaine, Lidocaine), other active substances (Caffeine, Paracetamol). · Diluents: Lactose, Mannitol, Glucose, Soda.
Cocaine purity in the samples analysed ranges from 50 to 60%.
The retail price of cocaine ranges between 58.30 and 87.40 Euros per dose and the trafficking price ranges from 29,130 to 58,260 Euros per kg.
139 13.3.2 Trafficking, dealing and distribution patterns
The Police describes the recent distribution patterns of cocaine in the domestic illegal market as “dynamic”, since this market has been broadened by new user groups, coming from various socioeconomic backgrounds.
Cocaine trafficking is limited among friends or acquaintances; is it not found as yet in the open street market.
Supply routes
Data from seizures indicate that 67% of cocaine is transferred by sea, 25.5% by road and 7.7% by plane. A new popular route for small amounts is via courier services.
Cocaine is imported in Greece mainly from Latin America, Bulgaria, Albania and the Netherlands.
13.4 Intervention projects
Intervention projects especially designed to cocaine users do not exist. According to health professionals working in the treatment sector, users who approach the therapeutic programmes having cocaine as their main substance of abuse are very few. The need for the implementation of specilised programmes has not arisen yet.
14. INFECTIOUS DISEASES
14.1 Prevalence of HCV, HBV and HIV among drug users
14.1.1 Hepatitis
As mentioned in Chapter 3.3, the Greek Focal Point receives data on hepatitis from various sources in aggregated form.
As the prevalence for hepatitis B among drug users is quite low, the discussion will be mainly focused on hepatitis C, which consists the biggest problem related to infectious diseases in Greek drug users.
Data are classified according to their nature (test-results or self-reports) and according to the type of source.
· Test results in 1999
Public Laboratories in Athens
The Laboratory of Syngros General Hospital and the Laboratory of the National School of Public Health are the two major Reference Centres for hepatitis B and C testing. Most therapeutic centres in Athens sent their clients
140 for medical tests in these centres. Users tested there are mostly injectors, but for the moment they are not separated from the overall number of users.
In the Syngros Laboratory, out of the 327 drug users tested for hepatitis B 14 (4.3%) were found infected, and out of the 317 tested for hepatitis C, 178 (56.1%) were found infected (Figure 31).
In the laboratory of the National School of Public Health (NSPH), out of the 393 users tested, 8 (2%) were infected with hepatitis B and 162 (41.2%) with hepatitis C (Figure 31).
Therapeutic programmes
Test results from the methadone substitution programme, implemented by OKANA, derive from two out of its four units, which function in Thesaloniki. Out of the 174 intravenous drug users tested, 11 (6.3%) were found infected with the hepatitis B virus and 142 (81.6%) with the hepatitis C virus (Figure 31).
Data from one of the two major drug-free therapeutic agencies, the Centre of Therapy for Dependent Individuals (KETHEA) indicate that out of 286 IVDUs tested, 10 (3.5%) and 148 (51.7%) had hepatitis B and C respectively (Figure 31).
The Psychiatric Hospital of Attica (Athens Prefecture) has a special unit for dependent individuals, 18 ANO, which has implemented a special programme for women. Of the 72 women treated since the programme started, i.e. in the last 3 years, 4 (5.5%) had hepatitis B and 31 (43%) hepatitis C (Figure 31).
In the Greek prisons, testing for infectious diseases is voluntary but encouraged. Of the 130 IVDUs tested in 1999, 68 (52.3%) were infected with hepatitis B and 82 (63.1%) by hepatitis C.
Test results data are summarised in Figure 31.
SOURCES: Andreas Syngros Hospital, NSPH, OKANA, KETHEA, 18 ANO, Ministry of Justice, 2000.
Figure 31: Test results for Hepatitis C as reported by the various relevant sources in 1999
% 90 81,6 80 70 63,1 56,3 60 51,7 50 41,2 43 40 30 20 10 0 Syngros NSPH Substitution KETHEA 18 ANO Prison Hospital Units Programe for inmates women users 141 The highest percentage of users infected with hepatitis C is found in the substitution programme. Clients there are, heavy users, have a long drug career and several drug-related health problems, because they are selected on the basis of such criteria.
The vast majority of the users infected in the above sources were men, as the majority of their clients are also men. In most cases infected users belong to the 25-35 age group; as expected, in the substitution programme, most of them are older, over 35.
· Self-reports in 1999
Data from the Treatment Demand Indicator show that out of the 1,096 users interviewed in 1999 696 (65.6%) reported having had a test for infectious diseases, 32 out of which did not know the test result. Of the rest, 70 (10.5%) reported hepatitis B infection and 285 (42.9%) reported hepatitis C.
Self-reports from KETHEA deriving from the 1,474 users interviewed in 1999 with the TDI protocol, show that 22% were infected with hepatitis C.
Data from KETHEA’s adolescent and young adults unit “STROFI” for 1999, show that the majority of adolescents had never had a test for any other infectious diseases. Of those who had, 4.7% were infected with hepatitis C and 1.1% with hepatitis B. The low percentages can be attributed to the young age of the population and the fact that intravenous use among them is rare - they are mostly cannabis users.
The Psychiatric Hospital of the Korydallos Athens prison uses the TDI protocol, as said in previous sections. Self-reported data from this source indicated that of the 35 inmates tested, 8.6% were found infected with hepatitis B and 25.7% with hepatitis C.
Self-reported data from the above sources are summarised in Figure 32.
SOURCES: Greek REITOX Focal Point, KETHEA, Korydallos Prison, 2000
Figure 32: Self-reports for Hepatitis C in 1999
% 50 45 42,9 40 35
30 25,7 25 22 20 15 10 5 0 TDI KETHEA Prison inmates
142 Self-reported hepatitis prevalence rates are quite lower than those coming from actual tests performed. It seems that users are either not altogether truthful about their health status, at least concerning infectious diseases, or not aware of their situation, or probably both. Whatever the case, the underreporting prevalent in self-reported data indicates that their reliability is low.
14.1.2 HIV/AIDS
AIDS prevalence in Greece among IVDUs remains low compared to other European countries, although a trend towards stabilisation appears in Europe too in the last years.
According to data from the Centre for the Control of AIDS and STDs (KEEL) in 1999 the overall number of new AIDS cases was 98, out of which 4 were intravenous drug users, most them belonging to the 15-39 age group (Figure 33).
Figure 33: AIDS cases among drug users (1985-1999)
N 12 11 10 10 9 8 8 6 6 6 5 5 4 4 4 3 2 2 1 1 0 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
SOURCE: Centre for the Control of AIDS and STDs, 2000.
The low prevalence of AIDS appears contradictory to the high prevalence of needle sharing and other risk behaviours among IVDUs, as discussed in previous sections. Qualitative data that the Focal Point has collected indicate that health professionals are trying to interpret the phenomenon. Several of them foresee a sharp increase in the years to come, as in Greece issues related to drugs appear usually later that in other European countries. Nevertheless, one of the possible interpretations that key-experts offer is that Greek IVDUs share needles only with relatives or close friends they know well and this minimises the risk of getting infected. Another interpretation is that Greek IVDUs, belonging to a marginalised and socially excluded social group,
143 do not travel abroad and their contacts with IVDUs from other European countries, where the virus is more prevalent, is limited.
14.1.3 Data on infectious diseases from special studies
The interest shown in the investigation of HIV/AIDS prevalence among drug users in the beginning of the 90’s has, in the last years subsided, probably because the prevalence of this infectious disease is low in Greece.
In the last few years two studies have examined the risk behaviour and the prevalence of infectious diseases among prison inmates in Greece. These studies have already been mentioned in this report when risk behaviours were discussed (see Chapters 2.2 Drug use in the population and 2.3 Problem drug use). Here, their findings relevant to the prevalence of infectious diseases, will be presented.
The OKANA study in prisons, conducted in two Greek prisons, examined the prevalence of HIV and hepatitis among injecting and non-injecting drug users (Table 20).
Table 20: Prevalence of HIV and hepatitis in Greek prisoners
IVDus Non-IVDUs (365) (168) % % Anti-HIV -1 0.31 0 Anti-HCV 80.6 9.5 Anti-HBc 67.2 46.4 HBsAg 7.2 4.8 Anti-HDV 3.3 0
1 One user
SOURCE: Malliori et al. 1998
The difference between injecting and non-injecting drug users is great in all categories; injecting drug users seem to be at higher risk for all infectious diseases than those users who do not inject. This is particularly true for hepatitis C, where the majority of injecting users (80.6%) are infected with. Only one injecting user was found infected with HIV. The most important risk factors for HCV infection were injecting while in prison and multiple imprisonments (Malliori et al. 1998).
144 As discussed in Chapter 2.3.2 Risk behaviours in a study conducted by the National School of Public Health, needle sharing among injectors decreased between 1993 and 1998, while use of condoms increased. As a result, the percentage of seropositive users decreased from 2.5% in 1993 to 0.8% in 1998. On the contrary, the prevalence of infectious diseases increased; whereas in 1993 no user was found positive for hepatitis B or C, in 1998, 4.9% of the users were found positive for hepatitis B surface antigen (HbsAg and 49.4% positive for hepatitis C) (Kornarou et al. 1999).
14.2 Determinants and consequences
The risk behaviours exhibited by drug users have been discussed in detail in Chapter 2.3. It was emphasised that a high percentage of intravenous drug users share needles with each other and that this behaviour takes the form of a ritual in Greece with which users prove their trust and friendship.
A large number of IVDUs have not been tested for infectious diseases. The number would probably be higher if the therapeutic centres did not consider medical tests as a prerequisite for admission. Even among users who take the test, a large percentage do not ask for the result. This “voluntary ignorance” might be an inhibitory factor to prevention, as, it has been found that, at least for HIV, knowledge of one’s own positive serostatus resulted in them taking increased precautions (using condoms, avoiding lending needles to others) to protect their friends from catching the disease (Schlumberger et al. 1999).
Although HIV remains at low levels hepatitis prevalence is high. Programmes on safe use have been implemented in Greece in the last few years. It is perhaps very early to expect quantifiable results.
14.3 New developments and uptake of prevention, harm reduction and care
Due to the alarming spread of STDs among the drug users population, various agencies have become actively involved in preventing infectious diseases and in promoting harm reduction from drugs. Their interventions range from education on safe drug use and safe sex to syringe exchange, testing and treatment (Table 1).
Therapeutic programmes and low threshold services systematically organize seminars on safe drug use, prevention of infectious diseases and hygiene issues. For example, the KETHEA Multiple Intervention Centre, in collaboration with the Centre for the Control of AIDS and STDs (KEEL) and the “Médecines sans Frontières” association, implements on a fortnight basis specialized seminars to drug users who approach the Centre. These seminars deal with the following issues: a. interactive effects of drugs and associated risks, b. information on harm reduction, c. prevention from AIDS and Hepatitis B and C, and d. first aid information. Regular educational seminars on safe
145 drug use and prevention of infectious diseases are also organized by the Social Service of OKANA Help Centre.
Moreover, treatment and low threshold services provide their clients with the opportunity to have infectious diseases or other health-related tests, in cooperation with general hospitals and local health services. In this context, the Therapeutic Community “EXODOS” of KETHEA has organized since 1998 case-history records for all clients and it has also implemented in collaboration with the General Hospital of Larissa a vaccination programme for Hepatitis B available to all persons in treatment. The OKANA Help Centre also offers testing possibilities through its general health clinic and the fully equipped Microbiological Laboratory established in 1999. Clients of the substitution programmes in Athens as well as drug users approached by the OKANA streetwork programme are referred to the medical services of the OKANA Help Centre.
The role of the streetwork programmes in preventing infectious diseases is of outmost importance. Apart from referrals to general hospitals for infectious diseases and other medical tests, they also provide on site information and counselling on harm reduction, on safe drug use and on safe sex. In addition, the OKANA streetwork programme distributes clean equipment for drug use (i.e. syringes and serum), while it motivates drug users to exchange their used syringes with clean ones. Syringe exchange takes place within the premises of the OKANA Help Centre. In order to promote safe sex, both streetwork programmes in Athens distribute condoms to drug users.
Treatment and psychological support to infected individuals are provided by the hospital “Andreas Syngros” in Athens as well as by general hospitals at regional level. Table 21. Programmes and interventions for combating infectious diseases
Programmes / Agencies Type of Interventions · Health promotion programmes to students Prevention centres · Information and sensitisation seminars to students, to health professionals and to the general public · Seminars on prevention of infectious diseases Specialized Therapeutic Programmes · Referrals to general hospitals for testing and vaccination · Seminars on safe drug use, safe sex and prevention of infectious diseases
Low Threshold Programmes · Counselling and social services · Exchange of syringes · Referrals to general hospitals for testing, vaccination and treatment
(continued to next page Ê)
146 (continued from previous page È)
· Information and counselling on safe drug use, safe sex, prevention of infectious diseases · Distribution of information leaflets, condoms Streetwork Programmes and syringes · Referrals to the medical services of the OKANA Help Centre and to General Hospitals for testing and vaccination Seminars on health issues and on prevention of Programmes in Prisons infectious diseases to prisoners and personnel · Monitoring prevalence of HIV · Distribution of informative leaflets · Specialized telephone help line · Counselling, psychological, psychiatric and social services · Seminars addressed to doctors, nurses, Centre for the Control of AIDS and STDs mental health professionals, students, police (KEEL) officers, local agencies · Cooperation with specialized therapeutic programmes for seminars on safe drug use and sex · Research studies on infectious diseases Hellenic School of Public Health (reference · Testing and vaccination centre for infectious diseases) · Treatment Laboratory of the “Andreas Syngros” · Testing and vaccination Hospital (reference centre for infectious diseases) · Psychosocial services · Treatment Cooperation with specialized harm reduction Associations of volunteers (i.e. “Médecins programmes for seminars to drug users and sans Frontières”) personnel regarding health issues and prevention of infectious diseases
147 The Centre for the Control of AIDS and STDs (KEEL), which was established in 1992, has developed an well-organized network of prevention, treatment and social services. This is addressed to general population, and to infected persons and their families. Moreover, KEEL is considerable active in implementing training and research programmes regarding infectious diseases as well as in sensitizing the lay public through TV and radio broadcasts. Training of professionals in issues of infectious diseases is also provided in cooperation with European and international organizations. For example, in 1999 the KETHEA organized in collaboration with the Ministry of Health and the University of California (San Diego) a congress entitled “Use of psychoactive substances and HIV/AIDS: new research fields”.
Evaluation regarding prevention and care of infectious diseases has not been developed yet. Lack of specific indicators that would be included in the evaluation studies of the drug-specific treatment programmes and broader problems in the evaluation of streetwork programmes appear to be the main reasons for that. Nevertheless, according to more general health and harm reduction indicators, evaluation results seem to be positive. Substitution programmes refer a stable increase of the physical health improvement of their clients up to 80-90%, while the number of the syringes exchanged by the OKANA Help Centre in 1999 was considerably increased compared to those in 1998 (86,819 and 46,660 syringes, respectively). Moreover, while in 1998 1,297 drug users visited the medical services of the Help Centre, this number was increased in 1999 (1,747 drug users, from whom 621 were new clients).
However, several difficulties have been reported regarding prevention and care of infectious diseases. Although therapeutic and harm reduction programmes constantly refer drug users to general hospitals for medical and infectious diseases tests, they appear to be unwilling to have these tests or inquire about the results in many cases. Drug users seem to prefer medical services specifically addressed to them (i.e. OKANA Help Centre) to general hospitals. Moreover, they seem to be afraid of being stigmatized by the hospitals’ personnel. The latter is more common at the local and the regional level, where sensitization programmes are lacking. Another difficulty is the fact that some of the prevention and the therapeutic programmes (especially those of the public sector) do not organize education seminars regarding prevention of infectious diseases on a regular basis. Thus, on the grounds of these difficulties it seems to be necessary for prevention programmes of infectious diseases not only to be intensified by all therapeutic and prevention agencies, but also to be expanded at the local and the regional level.
148 REFERENCES
149 REFERENCES AND SOURCES OF INFORMATION
Kokkevi, A. (1992) A Follow up study of drug addicts in Greece. Preliminary Results. In: Epidemiologic Trends in Drug Abuse. Proceedings of the Community Epidemiology Work Group, December 1992, ‘pp. 441-452’. National Institute of Drug Abuse, Rockville.
Kokkevi, A. (1999) How can research data be linked to prevention action. In: Regional Congress “Preventive Psychiatry”, 24-28 February 1999, ‘p. 43’. World psychiatric Association, Athens.
Kokkevi, A. and Stefanis, C. (1991) The epidemiology of licit and illicit substance use among high-school students in Greece. American Journal of Public Health, 81, 48- 52.
Kokkevi, A. and Stefanis, C. (1993) Drug Use in Greece: Substance Use in the Student Population. Vol. 2. Biblioteca Psychiatrica, Athens.
Kokkevi, A.and Stefanis, C. (1994) Licit and Illicit Drug Use in Greece: Trends in the General and in the School Population. UMHRI, Athens.
kkevi, and Stefanis, C. (1995) Drug abuse and psychiatric comorbidity. Comprehensive Psychiatry, 36, (5), 329-337.
Kokkevi, A., Alevizou, S. and Liappas, J. (1991) Intravenous drug use and AIDS infection. In: Changing Psychiatry in Changing Societies, 23-25 August 1991. Hungarian Psychiatric Association, Budapest.
Kokkevi, A., Alevizou, S., Arvanitis, I., Liappas, S. and Stefanis, C. (1992) AIDS- related behaviour and attitudes among IV drug users in Greece. International Journal of the Addictions, 27, (1), 37-50.
Malliori, M., Kokkevi, A., Zafiridis, F., Hadzakis, A. and Stefanis, C. (1992) Intravenous drug use and high risk behaviour in HIV transmission. In: 3rd Panhellenic Congress on AIDS and Sexual Transmitted Diseases, 6-9 February 1992, ‘p. 89’. Hellenic Scientific Society for Research on AIDS and Sexual Transmitted Diseases, Athens.
Kokkevi, A., Liappas, J., Boukouvala, V., Alevizou, S., Anastasopoulou, E., and Stefanis, C. (1993) Criminality in a sample of drug abusers in Greece. Drug and Alcohol Dependence, 31, 111-121.
Madianou, D., Madianos, M., Kokkevi, A. and Stefanis, C. (1993) Drug Use in Greece: Substance Use in the General Population. Vol. 3. Biblioteca Psychiatrica, Athens.
Malliori, M., Economou M., Angelopoulos N., Katsoulidou, A., Kokkevi, A., Hatzakis, A. and Stefanis, C (1993) HIV-1 infection in intravenous drug users in Greece. In: AIDS and Drug Addiction in the European Community: Treatment and Mistreatment.
150 Proceedings on Seminar on AIDS and Drug Addiction, (ed. M. Reisinger ), ‘pp. 107- 114. European Monitoring Center for Drugs and Drug Addiction, Brussels.
Tsili, S. (1994) Construction and evolution of drug addict’s image, during the decade 1980-1990. Tetradia Psychiatrikis, 48, 109-112.
Chaidou, A. (1995) Drugs: current legislation and international trends. In: The Triangle of Encounter: Substance, Environment, Personality: the Phenomenon of Toxic Dependence, ‘pp. 66-82’. Hellenic Association of Local Government and Self- Government, Athens.
Fakiolas, N., and Armenakis, A. (1995) Delinquency and Aggressiveness of Adolescent Students, Specific Sociological Issues. Stamiri, Athens.
Liappas, J., Mellos, E., Pomini, V., Peppas, E., Kokkevi, A., and Stefanis, C. (1996) Suicidal and parasuicidal attempts in association to substance abuse in a sample of Greek drug users. In: Suicide : Biopsychosocial Approaches, 16-19 May 1996, ‘p. 103’. Athens.
Tsaclakidou, D., Kokkoris, C., Douzenis, A. (1996) Suicidal behavior in chronic intravenous heroin users (IVHU’s). In: International Conference: Suicide: Biopsychosocial Approaches, 16-19 May 1996, ‘p. 87’. Athens.
Douzenis, A., Tsaklakidou, D., Kokkoris, C. (1997) Greek methadone programme and minorities. In: T3 Semmer University ‘’Responding to Drug Use within Black Migrant and other Minority Communities’’, 23-26 June 1997. Bristol.
Marselos, M., Boutsouris, K., Liapi, H., Malamas, M., Kateri, M., and Papaioannou, T. (1997) Epidemiological Aspects of the Use of Cannabis among University Students in Greece. European Addiction Research, 3, 184-191.
European Commission (1998) Comparative Survey on HIV/AIDS Risk Behaviours in a Population of Young Marginalised People in 3 Southern European Cities. Caritas Diocesana di Roma.
STROFI (1998) Sociodemographic and other characteristics of individuals approaching STROFI in 1998. STROFI, Athens.
STROFI (1999) Sociodemographic and other characteristics of individuals approaching STROFI in 1999. STROFI, Athens.
Calafat, A., Stocco, P., Mendes, F., Simon, J., Wijngaart, van den G., Sureda, P., Palmer, A., Maalste, N. and Zavatti, P. (1998) Characteristics and Social Representation of Ecstasy in Europe. European Commission & IREFREA, Spain.
Kokkevi, A., Siamou, I., Politikou, K., Maka, Z. and Plagianakou, L. (1998a) Patterns of drug use among Athenian young people: comparative results from qualitative and epidemiological research. In: IFEFREA Seminar “New Frontiers, New Horizons”, Coimbra.
151 Kokkevi, A., Stefanis, N., Anastasopoulou, E., and Kostogianni, C. (1998b) Comorbidity in substance use and personality disorders. In: 15th Panhellenic Psychiatric Conference, 29 April – 3 May 1998, ‘p. 123’. Hellenic Psychiatric Association, Athens.
Liappas, I., Peppas, E., Pomini, V., Paparrigopoulos, T., Papavasiliou, P., and Christodoulou, G. (1998) Incidence of alexythymia, social phobia and depression-like symptomatology in a sample of alcohol and drug users. In: 15th Panhellenic Psychiatric Conference, 29 April-3 May 1998, ‘p. 239’. Hellenic Psychiatric Association, Athens.
Malliori, M., Sypsa, M., Psichogiou, M., Touloumi, G., Skjoutelis, A. Tassopoulos, N., Hatzakis, A. and Stafanis C. (1998) A survey of Bloodborne viruses and associated risk behaviours in Greek Prisons. Addiction, 93, (2), 243-251.
Pertesi, E., Fotiadou, A., Papamichail, E., Ilias, S., and Anifanti, A. (1998) Suicide attempts in dependent individuals. In: 15th PanHellenic Congress of Psychiatry, 29 April – 3 May 1998, ‘p. 33’. Hellenic Psychiatric Association, Athens.
Kalarritis, G. (1999) A comprehensive network of services for adolescent substance users and their families in Greece. In: The 38th International Congress on Alcohol, Drugs and other Dependences, 16-20 August 1999. International Council on Alcohol and Addictions, Vienna.
Ministry of Finance (1999) State budget for the year 2000. Athens.
Spinelli, K. (1999) Drugs : the phenomenon, its patterns, and a legal-political approach. Iperaspisi 4, 803-835.
Athanaselis, S., Dona, A., Papadodima, S., Papoutsis, G., Maravelias, C., and Koutselinis, A. (1999) The use of alcohol and other psychoactive substances by victims of traffic accidents in Greece. Forensic Science International,102, 103-109.
Kornarou, H., Trichopoulou, E., Kotsianopoulou, M., Georgiou, B., Papathanasiou, S., and Roumeliotou, A. (1999) Comparative study of changes in the attitude of Greek intravenous-drug users between 1993-1998, Hellenic Archives of Aids, 7, (1), 30-36.
Maka, Z., Terzidou, M., Spyropoulou, M. and Kokkevi, A. (1999) Differential psychosocial profiles of adolescent cannabis users in Greece in the last fifteen years: preliminary results. In: 5th Conference of the European Association of Substance Abuse Research, 7-9 May 1999. Ludwing-Boltozmann-Institute for Addiction Research at the Anton-Proksch-Institute, Vienna.
Malliori M., Chalkia G., and Bousiotis P. (1999) Comprehensive multidisciplinary strategy to drug abuse prevention: Translating policy into practice. In: Regional Congress of Preventive Psychiatry, 24-28 February 1999, ‘p. 90’. World Psychiatric Association, Athens.
152 Mavris, M., Spinellis, C., and Zagoura, P. (1999) Greece. In: Regulating European Drug Problems: Administrative Measures and Clinic Law in the Control of Drug Trafficking, Nuisance and Use, (ed. N. Dorn), ‘pp. 159-180’. Kluwer Law International, London.
Menoutis, V., Pavlopoulou, V. and Gemos, L. (1999) Drug use and attitudes towards drugs in training conscripts of the Hellenic Navy. In: the Regional Congress of Preventive Psychiatry, 24-28 February 1999, ‘p. 83’. World Psychiatric Association, Athens.
Mostriou, A., Lekakis, G., Kubi, E. and Malliori, M. (1999) Dealing with constraints for multi-disciplinary co-ordination of prevention work: a challenge for the training of professionals. In: Regional Congress of preventive Psychiatry, 24-28 February 1999, ‘p. 74’. World Psychiatric Association, Athens.
Papoutsopoulou, H., Lazarus, M. Barbanis, G. and Malliori, M. (1999) A prelimary assessment of the dental clinic at OKANA’s Help Centre. In: 19th National Dental Conference, 27-30 October 1999, ‘pp. 114-115’. Greek Dental Federation, Crete, Greece.
Poulopoulos, CH, and Tsiboukli, A. (1999) Socio-demographic differences, patterns of use and drop-out from Greek drug-free treatment programmes. Drugs: education, prevention and policy, 1, (1), 99-110.
Schlumberger, M., Desenclos, J., Papaevangelou, G., Richardson, C., and Ancelle- Park, R. (1999) Knowledge of HIV serostatus and preventive behaviour among European injecting drug users : second study. European Journal of Epidemiology,15, 207-215.
Siamou, I., Spyropoulou, M., and Plagianakou, L. (1999) Comparison of the psychological characteristics of drug using and non-drug using club/party goers. In: IREFREA Seminar “2000…The New Ways of Prevention”. Lyon.
Aristotelio University of Thessaloniki (2000) Evaluation Report of the Leonardo Da Vinci Research Program.: Needs’ and Methods’ Assessment for Vocational Training in Juvenile Delinquents and Adolescents in Danger, ORESTIS. Aristotelio University of Thessaloniki, Thessaloniki.
Dimitriou, A. (2000) Use of Psychotrpic Substances among High-school Students – Trends in Time. Unpublished doctoral dissertation, submitted to the University. Ioannina.
Georgakas, P. (2000) Study on the problems of children of drug dependent parents. Aristotelio University of Thessaloniki, Thessaloniki.
KETHEA (2000) The 1999 Annual Report of KETHEA. KETHEA, Athens.
Kitsos, G. (2000) Criminality in Drug Users and Social Exclusion. Unpublished Dissertation, submitted to the Panteion University of Athens. Athens.
153 Malliori, M. (2000) Drug use in prison. OKANA Greek report on the 3rd Meeting of the Group of Experts in Epidemiology of Drug Problems. Strasbourgh.
OKANA (2000) The reality about drugs and about the measures of dealing with the drug problem: Prevention-Treatment-Rehabilitation. Action Plan of the OKANA for the years 2000-2003: General Principles and Directions. OKANA, Athens.
Poulopoulos, Ch. (2000) Immigration and use of psychoactive substances. Piniki Dikeosini, (in press).
Boukouvala, V., Yotsidi, V., and Lyraki, Ch. (2000) Inventory of the Drug-specific Prevention and Therapeutic Services (revised edn). UMHRI, Greek Focal Point, Athens.
Kokkevi, A., Loukadakis, M., Plagianakou, S., Politikou, K., Stefanis, C. (2000a) Sharp increase in illicit drug use in Greece: trends from a general population survey on licit and illicit drug use. European Addiction Research, 6, 42-49.
Kokkevi, A., Terzidou, M., Politikou, K., and Stefanis, C. (2000b) Substance Use among High School Students in Greece: Outburst of Illicit Drug Use in a Society Under Change. Drug and Alcohol Dependence, 58, 181-188.
Koulierakis, G., Gnardelis, C., Agrafiotis, D, and Power, K. (2000) HIV risk behaviour correlates among injecting drug users in Greek prisons. Addiction, 95, (8), 1207- 1216.
Paralaimou, Z., Ploumidaki, A., and Yotsidi, V. (2000) Evaluation Report on the Difficulties and Needs of the Prevention Centres of OKANA and of Local Authority, (ed. A. Kokkevi). OKANA, Athens.
Terzidou, M., Richardson, C., Plagianakou, L. and Kokkevi, A. (2000) Drinking among Illicit drug users: trends in the general population. In: 6th Conference of the European Association of Substance Abuse Research, 18-20 October 2000. Munich.
Katerelos I. Drugs prevention policy: an experimental approach of the central nucleus of the social representation of drugs in Greek youth. (in press).
154 ANNEX
155 Table I. Prevention Centers established by OKANA (1997-2000) (Total Number: 51 Prevention Centres)
Geographical TITLE Town/City Inauguration Region Year THRACE 1) Information & Prevention Center Against Drugs Xanthi 1997 2) Information & Prevention Center Against Drugs Alexandroupoli 1998 «ELPIDA» 3) Prevention Center Against Substance Use «ORPHEAS» Komotini 1999 MACEDONIA 1) Communication & Prevention Center Against Katerini 1997 Psychoactive Substances «KEP PIERIAS» 2) Center for Preventing and Combating Drugs Kavala 1998 3) Drug Dependence Prevention & Health Promotion Center Thessaloniki 1998 «PYXIDA» 4) Prevention Center for Combating Substances «ELPIDA» Thessaloniki 1998 5) Prevention Center Against Drugs Florina 1998 6) Prevention Center Against Substances «ORIZONTES» Kozani 1998 7) Information & Prevention Center Against Drugs Kastoria 1999 «DIEXODOS» 8) Prevention Center Against Substance Use «PNOI» Chalkidiki 1999 9-10) Prevention Centers «SIRIOS» (2 Centers) Thessaloniki 2000 11 Prevention Center Against Substances «ORIZONTES» Grevena 2000 HEPIRUS 1) Counselling Center for Combating Drugs Ioannina 1996 2) Prevention Center Arta 1997 3) Prevention Center Against Substance Use «ARIADNE» Igoumenitsa 1999 4) Prevention Center Against Drugs and Other Substances Preveza 2000 «KE.PRO.NA.P.» THESSALIA/ 1) Social Intervention Center Trikala 1997 SPORADES 2) Prevention Center Against Dependence Karditsa 1997 3) Drug Prevention Center «PROTASI ZOIS» Volos 1998 4) Prevention Center Against Substances «ORPHEAS» Larisa 1999 CENTRAL 1) Drug Prevention Center Chalkida 1997 THESSALIA 2) «Protasi Zois - Drug Use Prevention» LIvadia 1998 3) Municipal Prevention Unit «ODYSSEUS» Agrinio 1998 4) Prevention & Information Center Against Drugs Lamia 1998 PELOPONNESE 1) Prevention Center Against Substance Use Amaliada 1998 «INTERVENTIONS» 2) Drug Prevention Center Patra 1998 3) Information - Prevention & Sensitization Center Against Kalamata 1999 Psychoactive Substances «KEPEPSO» 4) Prevention Center Against Substance Use «DIOLKOS» Korinthos 2000 ATTICA 1-3) Counselling Center Against Drugs «ODYSSEUS» Piraeus / Keratsini / 1997 (3 Centers) Nikaia 4-7) Drug Prevention & Health Promotion Center «ATHENA Athens 1998 HEALTH» (4 Centers) 8) Prevention & Information Center Peristeri 1998 9) Social Intervention Center –– Joint Municipal Enterprise Athens 1998 of Alimos, Argiroupoli, Elliniko & Glyfada 10) Center for the Prevention of Substance Use & the Zografou 2000 Promotion of Health
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Geographical T I T L E Town/City Inauguration Region Year IONIAN 1) Municipal Drug & AIDS Prevention Unit «NIKOS Corfu 1997 ISLANDS MOROS» 2) Drug Prevention Center Against Substances «STORGI» Zakinthos 1998 NORTHEAST 1) Prevention Center Against Substance Use Hios 1998 AEGEAN 2) Prevention Center Against Substance Use «PNOI» Lesvos 2000 3) Drug Prevention and Health Promotion Center Samos 2000 CYCLADES 1) Prevention Center Against Substances Paros 1998 2) Prevention Center Against Substances Siros 1998 DODECANESE 1) Drug Prevention Center «IPPOKRATIS» Kos 1999 2) Center for the Prevention of Substance Use and for Rhodes 2000 Health Promotion «DIMIURGIA» CRETE 1) Prevention Center Against Drugs Rethimnon 1997 2) Prevention Center Against Substances Hania 1998
157 Table II. Treatment units, geographical location & coverage (Total number: 28 Treatment Units)
UNITS PARENT INSTITUTION GEOGRAPHICAL LOCATION & COVERAGE Residential Treatment
«PAREMVASI» Alternative Therapeutic Community KETHEA Rafina (Prefecture of Attica) «NOSTOS» Therapeutic Community KETHEA Piraeus (Aegean Islands, Crete & Southern Greece in general)
«ITHACI» Therapeutic Community KETHEA Sindos, Thessaloniki (Northern Greece) «EXODOS» Therapeutic Community KETHEA Larissa (Central Greece) Residential Therapeutic Programme - Drug & Attica State Psychiatric Haidari (Prefecture of Attica) Alcohol Dependence Unit «18 » Hospital Drug Dependence Treatment Unit Thessaloniki State Thessaloniki (Northern Greece) Psychiatric Hospital «PHILIMON» Residential Therapy Centre for Drug- «PHILIMON» Pefki (Prefecture of Attica) Dependent Persons
Programme for Dependent Women – Drug & Attica State Psychiatric Filothei (Prefecture of Attica) Alcohol Dependence Unit «18 » Hospital Non-Residential Treatment Adults «DIAVASSI» Open Therapeutic Community KETHEA Athens «DIAVASSI» Evening Therapeutic Programme KETHEA Athens «IASON» Mental Health Centre Athens Programme for Individuals with Dual Diagnosis – Attica State Psychiatric Athens Drug Dependence Unit «18 » Hospital Therapeutic Programme « » Dept. of Psychiatry, Athens Medical School, University of Athens / OKANA Drug-Free Therapeutic Programme «GEFIRA » OKANA Patras (Peloponnese) Programme of Family Therapy & Counselling Attica State Psychiatric Athens Drug & Alcohol Dependence Unit «18 » Hospital Alternative Therapeutic Programme «ARGO» Thessaloniki State Thessaloniki (Northern Greece) Psychiatric Hospital Open Therapeutic Programme «ARIADNE» KETHEA Heraklion (Crete) Adolescents «STROPHI» Open Therapeutic Community KETHEA Athens Secondary Prevention Centre KETHEA Athens Department for Adolescents and Young Adults Attica State Psychiatric Athens Drug & Alcohol Dependence Unit «18 » Hospital Counselling Centre in the Public Prosecutors KETHEA Athens Office in Athens for Young Drug Users Offenders
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UNITS PARENT INSTITUTION GEOGRAPHICAL LOCATION & COVERAGE Substitution Programmes
Methadone Substitution Programme, 1st Unit OKANA Athens Methadone Substitution Programme, 2nd Unit OKANA Athens Methadone Substitution Programme, 1st Unit OKANA Thessaloniki Methadone Substitution Programme, 2nd Unit OKANA Thessaloniki Methadone Maintenance Programme OKANA Athens Low Threshold Programmes
Multiple Intervention Centre KETHEA Athens Help Centre OKANA Athens
159